ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL 400 W Congress #521 Tucson AZ 85701-1352 (520) 628-6595 800 W Washington 5th Floor Phoenix AZ 85007-2934 (602) 542-5141 ACT OF VIOLENCE REPORT Regulation Statute A.R.S. 4-244.367 DEFINITION: 4-101 (1) "ACT OF VIOLENCE" means an incident consisting of a riot, a brawl or a disturbance, in which bodily injuries are sustained by any person and such injuries would be obvious to a reasonable person, or tumultuous conduct of sufficient intensity as to require the intervention of a peace officer to restore normal order, or an incident in which a weapon is brandished, displayed or used. A.R.S. 4-244.367 It is unlawful for a licensee to fail to report within 7 days an occurrence of an act of violence to either the department or a law enforcement agency. Licensee/Agent's Name: (Exactly as it appears on license) Last First Middle Liquor License Number: ________________________ Business Name (NOT a corporate name): Business Address: Street City State 1. Date of this report: ______/______/_____ Date/Time of incident: ______/______/_____ Mo Day Yr Mo 2. What police authorities were summoned? Day Yr Zip _____:_____ Hr Min AM PM Police Report #: Who called police? Was an arrest made by the police? YES NO 3. What emergency services were summoned? Who called for these services? 4. Was a weapon used or displayed? YES NO If yes, what type of weapon? 5. Identify or describe participants: 6. Name of person injured and type of injury: Person Type of Injury a) b) c) List Additional Person(s) and Injuries on back or next page GIVE DETAILS ON BACK OF SHEET OR NEXT PAGE FOR LIQUOR DEPARTMENT USE ONLY LIC0108 05/2004 *Disabled individuals requiring special accommodations, please call the Department. American LegalNet, Inc. www.FormsWorkflow.com 7. Give details of incident: Use Additional Sheets if Necessary X (Print name of person preparing this report) (Title or position held) THE CONTENTS OF THIS REPORT ARE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. X (Signature) LICENSEE: YOU SHOULD MAINTAIN A COPY FOR YOUR RECORDS. American LegalNet, Inc. www.FormsWorkflow.com