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Appendix E

CITY OF ___________________ POLICE DEPARTMENT

City ___________________ , State ____________

Case No. ________________

BUILDING EVACUATION NOTICE

The undersigned acknowledges being advised by the witnessing officer of the

_____________________________ Police Department of the possible existence of an

explosive device on the premises. Having been so advised, I have decided not to order

an evacuation of all persons from the premises.

Dated this _________________ day of _________________________ , 20 ______

Time _______________________________________________________________

Owner or Agent ______________________________________________________

Name of Business ____________________________________________________

Address ____________________________________________________________

Witnessing Officer ____________________________________________________

REFUSED TO SIGN THIS DOCUMENT AFTER BEING ADVISED OF THE ABOVE PARAGRAPH.

Officer _______________________________________ Date __________________

November 2010 Version 3.1.1 A-27


Emergency Operations Sensitive
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November 2010 Version 3.1.1 A-28


Emergency Operations Sensitive

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