Wilson, North Carolina


Appointment of Police Officers as Agents


To the Officers of the Wilson Police Department:


I, (Name) ____________________________, appoint each officer of the Wilson Police Department as agents for the purpose of forbidding any persons from entering upon or remaining on my property located at (Address) _______________________, Wilson, NC and for ordering trespassers to immediately leave the property.


I understand that arrests may be made for trespassing under N.G.G.S. 14-59.13 based on this grant of agency, and I agree to testify in court in any case where my testimony may be necessary.


This, the ________ day of ____________________, ________.



Owner / Occupant of Property


(______) ___________________

Telephone Number





I, (Name) ___________________________, a notary public of _____________ County, certify that ____________________________ personally appeared before me this day, and duly sworn, stated that in his/her presence _____________________ signed the forgoing instrument.


Witness my hand and official, this the ______ day of _____________, ______.


(Official Seal)                                     _______________________________

                                                                        Notary Public


My commission expires:                              __________________



This form needs to be updated in twelve months or sooner if there are any changes in this information.

Revised 05-04-2004