Responsible Alcohol Seller Program ABC Incident Report Date: Time: am/pm Store Address: Store Phone Number: Employee(s) Name: Employee(s) Address: Employee(s) Phone Number: Type of Incident: (Circle answer) Shoplifting Robbery Assault Damage to Property Suspect(s) Description: (Please circle appropriate answer) 1. 2. 3. 4. 5. 6. 7. 8. 9. Male or Female Black or White or Hispanic or Asian or Native American or Indian or Middle Eastern or Unknown Approximate Height – under 5 feet or between 5’1” and 5’5” or between 5’6 and 6’ or over 6’ Did the person wear a mask over their face? Yes or No (if yes, describe)__________________________ Did the person(s) have facial hair? Yes or No (if yes, describe)__________________________________ Hair Color – Black or Brown or Gray or Gray and Black or Red or other (if other, describe)_________ Was hair long or short? Long or medium or short or shaved head Describe how were they dressed? _________________________________________________________ Did they say anything? Yes or No (if yes, describe ) (Continue on back if necessary) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 10. Did they have an accent? Yes or No (if yes, describe) _________________________________________ 11. What is their approximate age? under 16 or 18-21 or 22 – 25 or 26 – 30 or 31 – 35 or 36 – 40 or over 40 12. Did you notice any tattoos, jewelry, or other identifying marks? Describe _________________________ American LegalNet, Inc. www.FormsWorkflow.com Responsible Alcohol Seller Program ABC Incident Report (page 2) Suspect(s) Vehicle (Please circle appropriate answer) 1. 2. 3. 4. 5. 6. 7. 8. Describe the Vehicle: car or pick up or van or motor cycle Color of vehicle: ________________________________ Tag number of vehicle: ___________________________ What state is the tag issued to? _____________________________ Are there any dents in the body? ____________________________ Is there anything else that makes it unique? ____________________________ Was someone else driving? Yes or No (Describe: ____________________________________) What direction did they go? __________________________________________________________ Type of Weapon (Please circle appropriate answer) 1. Did they display a weapon? Yes or No 2. What type of weapon? Knife or Hand Gun or Shot Gun or Rifle or other weapon (Describe: ____________________________________________________________________________ 3. Did they use the weapon? Yes or No What did they take? 1. Did they take money? Yes or No (if yes, how much?)__________________________________ 2. Did they take merchandise? Yes or No ( if yes, what?) ____________________________________________________________________________________ ____________________________________________________________________________________ Were there any witnesses? Yes or No (if yes, list names, addresses and phone numbers on back of this form?) Describe what happen? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com