SERVICE REFUSAL REPORT A.R.S. §4-244.14. For a licensee or other person to serve, sell or furnish spirituous liquor to a disorderly or obviously intoxicated person, or for a licensee or employee of the licensee to allow or permit a disorderly or obviously intoxicated person to come into or remain on or about the premises, except that a licensee or an employee of the licensee may allow an obviously intoxicated person to remain on the premises for a period of time of not to exceed thirty minutes after the state of obvious intoxication is known or should be known to the licensee in order that a nonintoxicated person may transport the obviously intoxicated person from the premises. For the purposes of this section, "obviously intoxicated" means inebriated to the extent that a person's physical faculties are substantially impaired and the impairment is shown by significantly uncoordinated physical action or significant physical dysfunction that would have been obvious to a reasonable person. 1. Date of this report: ________/______/________ month day year Date/Time of incident: ________/______/________ month day _____:_____ year hour minute (approx) Name of liquor licensed establishment: _________________________________________ Physical address of licensed establishment: ___________________, ____________, __________ street address city zip code Phone number of liquor licensed establishment: (________)__________-________________ 2. What police authorities were summoned? ______________________________ Police Report #: ________________________ Who called police? _______________________________ first and last name Was an arrest made by the police? YES NO Who was arrested? _________________________ 3. What emergency services were summoned? __________________________ Who called for these services? _______________________________ first and last name 4. How many drinks was the patron served throughout his/her visit? ______________________ American LegalNet, Inc. www.FormsWorkFlow.com 5. Identify or describe participants/intoxicated persons using a copy of their ID or information recorded from their ID. Provide their cell phone or daytime contact number. Participant #1: __________________________________________________________________ ______________________________________________________________________________ Describe this person’s appearance of intoxication: a) ____________________________________________________________________________ b) ____________________________________________________________________________ c) ____________________________________________________________________________ How were they removed from the premise? _____________________________________________ ________________________________________________________________________________ Participant #2: __________________________________________________________________ ______________________________________________________________________________ Describe this person’s appearance of intoxication: a) ____________________________________________________________________________ b) ____________________________________________________________________________ c) ____________________________________________________________________________ How were they removed from the premise? _____________________________________________ ________________________________________________________________________________ (attach additional sheet if necessary) 6. List any witnesses independent or staff: Witness #1: ___________________________________, _____________ first and last name staff or independent Witness #2: ___________________________________, _____________ first and last name (attach additional sheet if necessary) staff or independent 7. Name of person/persons injured and type of injury: Injury #1: ___________________________________, ________________________ first and last name type and location of injury Injury #2: ___________________________________, ________________________ first and last name (attach additional sheet if necessary) type and location of injury 8. Provide details of evidence as to how much the person consumed by credit tabs, servers personal knowledge or register tapes and attach to this document: American LegalNet, Inc. www.FormsWorkFlow.com 9. In your own written words, give details of incident separate page and attach to this report. Please include answers to these questions in your eyewitness report. • What time did the person enter? ___________ • What time was the person first observed to be intoxicated? __________ • Was the patron/patrons cut off immediately? YES NO • What time did the alternative ride remove the patron? ____________ • Who gave the alternative ride, if it was a sober companion use their name? • Who kept control and sight of the patron or patrons to verify that he/she was safe and did not consume more alcohol? • What are the names of the intoxicated patrons companions? • How many drinks and what type did the intoxicated patron/patrons consume? • What time were each of these drinks consumed (if you know)? YES NO • Were the companions found alternative rides as well? • List witnesses who observed the actions taken with the intoxicated patron? • Who were the servers? • Where was the intoxicated patron or patrons seated throughout the night? NO • If they drove away, did you obtain a plate number and call the police? YES • Was the patron cut off merely for the amount consumed without any signs or symptoms of intoxication? YES NO THE CONTENTS OF THIS REPORT ARE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. _____________________________________________________, _________________________ signature of person preparing this report today’s date ______________________________________________________, ________________________ printed first and last name of person preparing this report _________________________________ daytime contact number title or position held _________________________________ alternate contact number DLLC 5/2009 American LegalNet, Inc. www.FormsWorkFlow.com