Smoking Ordinance Complaint

Establishment Information

Name of Establishment:

Type of Establishment:

Street Address:

ZIP Code:

Phone Number:

Complaint Information

Date of Occurrence: mm/dd/yyyy format

Time of Occurrence:

Type of Violation: (check all that apply) Customer Smoking
Employee/Owner Smoking
No-Smoking sign not posted
Ashtrays/Smoking paraphernalia
Smoking allowed in no-smoking area
Person in charge fails to inform violator(s) to stop smoking
Other (please describe below)

Brief description of the violation:

Complainant Information

Name:

Phone Number:

E-Mail Address:

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