Colorado Department of Revenue Liquor and Beer Code Violation Hearing Report Form Liquor Enforcement Division, 1881 Pierce Street, Suite 108, Lakewood, CO 80214-1495 Phone: 303-205-2306 FAX: 303-205-2341Website: WWW.Colorado.gov/Revenue/Liquor LOCAL AUTHORITY NAME: City County ________________________________________________________ Licensee’s Name ___________________________________________________ Trade name: ___________________________________________________ Licensee’s Address: ___________________________________________________ ___________________________________________________ State License Number: ___________________________________________________ Date of Hearing: ___________________________________________________ Description of violations found: (Example) Sale to Minor not 12-47-901(1)(a) _________________________________________________________________________ _________________________________________________________________________ PENALTY INFORMATION Licensee had had not received Server Training Prior to violation. Violating Employee had had not received Server Training prior to violation. Licensee renewal denied, State should should not close this account License revoked______________________effective date License suspended for ____________________total days Actual day(s) served________________________ Day(s) of suspension held in abeyance ___________for the period of ____________ Amount of any fine paid in lieu of active suspension $_________________________ License denied/withdrawn (reason denied/withdrawn) ________________________ Other sanctions/Information __________________________________________________ _________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com