NEW ALBANY POLICE DEPARTMENT - New Albany, Ohio

ADDENDUM D
LOCKOUT/PUSH BUMPER RELEASE FORM
Lockout Release
Push Bumper Release
Report
Number:
Officer: Date: Time:
Location:
Requestor’s Information:
Vehicle Information:
Name:
OLN
or
SSN
Address:
City:
Year:
Make:
Model:
Color:
State: Zip: License
Plate
Phone #:
Number:
State:
Release:
I do hereby release and forever discharge, and agree to hold harmless, the New Albany Police Department, the Mayor, the Chief
of Police, City Council, and all officers, agents, and employees from all liability, claims, demands, damages, and causes of action
whatsoever.
This especially pertains to Officers of the New Albany Police Department using lockout tools and/or push bumpers on my motor vehicle,
described above, to gain entry into and/or move said vehicle.
Requestor’s Signature:
Witness’s Signature:
Witness’s Name
(Printed):
Disposition: Entry Gained
Entry Not Gained
Vehicle pushed off roadway
Vehicle not pushed off roadway
Other/Additional Information:
_________________________________________
_________________________________________
PD-04-101
Revised December 14, 2010