What is the address of the business or other location?

*Street Address:

Address line 2:

*City:

*State:

*Zip Code:

If submitting for a business complex or range of addresses, please complete a TLC for each address.

*Location Name:

*What is your authority to file a Trespass Letter of Consent?

*What is your Name?

*Date of Birth?

What is your mailing address?

*Street Address:

Address Line 2:

*City:

*State:

*Zip Code:

*What is your email address? This will be the primary method for seeking annual renewals of the TLC.

*Sometimes the police need to contact a responsible person to, for example, secure a door that won't lock or repair a broken window. Please provide a 24-hour phone number:

If you are not the person the police should contact, please provide that person's name:

Authority:

24-hour phone number:

Generally, Keizer police officers will not enforce trespass laws at rented or leased housing except at the request of a responsible person on scene or whom we will contact using the information provided above.

I do hereby designate each and every police officer, now and hereafter, employed by the City of Keizer as my agent and representative for the purpose of enforcing sections 164.245 and 164.255 (Criminal Trespass) of the Oregon Revised Statute.

Unless canceled or revoked, a TLC authorization will continue in full force and effect until the end of the calendar year plus 30 days. Prior to the end of each calendar year, we will solicit you for the following year's TLC.

By submitting this document with my typed signature, I authorize the Keizer Police Department to take action as set forth herein as if I had signed this form in person.

*Date and typed signature: