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Smoking Ordinance Complaint

Establishment Information
Name of Establishment:
Type of Establishment:
Street Address:
ZIP Code:
Phone Number:

Complaint Information
Date of Occurence:  mm/dd/yyyy format
Time of Occurence: :   
Type of Violation:
(check all that apply)

Brief description of the violation:

Complainant Information
Phone Number:
E-Mail Address:

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