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

STATE OF NORTH CAROLINA

WILSON COUNTY

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: __________________

Date

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

Revised 05-04-2004