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Your Information
* Last Name:
* First Name:
Address:
City:
State:
Zip:
* Phone
(i.e. (702) 759-1000)
* Email Address:
Complaint Information
* Date of Violation:
(i.e. 1/16/2007)
* Approx. Time of Violation:
a.m.
p.m. (i.e. 8:30)
What are you reporting? (Check all that apply)
Customer or Employee Smoking
No-Smoking Signs Not Posted
Smoking Materials Present (ashtrays, matches, etc.)
* Establishment Name:
* Street Address:
* City:
Zip:
Comments:
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