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DATE & TIME OF INCIDENT:                                                         ARREST:  YES             NO


            You,                                                                    , are hereby notified pursuant to Massachusetts General Laws, as amended, Chapter 266, section 120, that you are hereby barred from entering in or upon the premises or curtilage of the property owned by the Berkshire Athenaeum located at 1 Wendell Avenue in the City of Pittsfield, Massachusetts.

            Further, you are hereby notified that if you are found entered upon the above premises located in Massachusetts after the date of                                               , your presence shall be deemed a trespass upon said property herein described and the owner, or duly authorized representative shall take every measure permitted by law to prevent such trespass, which shall include arrest by a police officer.

I, (print name)      __________________________________________________________________

Of (address)        __________________________________________________________________

(city)                                                     (state)                       (zip code)__________  

Social Security Number             -            -                                Date of Birth   _____  / _____ /  _____  

I have fully read and understand the significance of the above notice of trespass and voluntarily affix my signature.

(signature)                                                                               (date)          

WITNESSED BY:    ______________________________________________________________


REASON:   _____________________________________________________________________   


Updated December 2010.  

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Berkshire Athenaeum, Pittsfield's Public Library, Pittsfield, Massachusetts