INCIDENT REPORT Most businesses that sell alcohol obey the liquor laws and want to be good neighbors. But sometimes problems do occur. If you have a complaint about the customers of a business that sells alcohol, please fill out this form and return it to the nearest OLCC office. An inspector will read your report and decide what action to take. We can enforce the liquor laws best when people with a complaint identify themselves and are willing to testify about the incident. But we will also take complaints from people who don't want to testify or give their names. Name of Business Involved:___________________________________________ Date of Incident:___________ Address of Business:_____________________________________________________________________________ Time Incident Occurred (from)__________(to)__________ Number of People Involved______ Type of incident (Please check): q shooting/stabbing q verbal threat q prostitute solicitation q fighting q harassment q shouting/yelling q assault Where did the incident occur: q inside the business q right outside of the business q in the parking lot q on the sidewalk next to the business q in the street near the business q other:__________________ q q q q q q q drinking in public loud music from business gang activity loud argument loud music from vehicle drug activity urinating in public noisy vehicle pushing/shoving q trespassing on public property q alcohol-related litter q other:____________________ q q Check if appropriate: q someone was injured q weapon involved business employees intervened q 9-1-1 was called Time:_______ q police came q the business was called Time of Call:______ Who did you talk to:_________ ____________________________________________ q Can you identify anyone who was involved in the incident or who was a witness? q Yes q No (please identify on the back of the form.) Did the incident involve a patron of the business? q Yes q No If so, did you see the person(s): q Buy or consume alcohol there q Come out of the business q Go into the business q Other:_________________ Your name______________________________________ Phone (home)______________ (work)_____________ Address:_______________________________________________________________________________________ Are you willing to testify about this incident? q Yes q No Today's Date:_________________________ Please describe the incident in your own words on the back of this form. This will help us a lot. Promoting Responsible Alcohol Sales and Service 9079 SE MCLoughlin Blvd. l Portland, OR 97222-7355 Ph (503) 872-5000 l Fax (503) 872-5042 l toll free (800) 452-6522 www.olcc.state.or.us American LegalNet, Inc. www.FormsWorkflow.com R64 (rev. 01/02) Please describe the incident: If you view the incident as serious, send this form to the nearest OLCC office immediately. Otherwise, you may wish to save the forms and send them in monthly. PORTLAND MAIN OFFICE 9079 S.E. McLoughlin Blvd. Portland, OR 97222 Mailing address: P.O. Box 22297 Milwaukie, OR 97269-2297 Phone: (503) 872-5000 Fax: (503) 872-5074 Toll free in Oregon: (800) 452-6522 BEND 20360 Empire Ave., Suite B-3 Bend, OR 97701 Phone: (541) 388-6292 Fax: (541) 388-6321 EUGENE 927 Country Club Road, Suite 200 Eugene, OR 97401 Phone: (541) 686-7739 Fax: (541) 687-7381 KLAMATH FALLS 107 S. 7th Klamath Falls, OR 97601 Phone: (541) 883-5600 Fax: (541) 883-5507 MEDFORD 15 Crater Lake Avenue Medford, OR 97504 Phone: (541) 776-6191 Fax: (541) 265-4521 NEWPORT 715 S.W. Fall St. Newport, OR 97365 Phone: (541) 265-4522 Fax: (541) 265-4521 NORTH BEND 1860 Virginia #10 North Bend, OR 97459 Phone: (541) 756-1520 Fax: (541) 756-2038 PENDLETON 700 S.E. Emigrant, Suite 140, #12 Pendleton, OR 97801 Phone: (541) 276-7841 Fax: (541) 278-4086 ROSEBURG State Office Building 251 N.E. Garden Valley Blvd. Suite A-3 Roseburg, OR 97470 Phone: (541) 440-3362 Fax: (541) 440-3361 SALEM 213 Madrona Street S.E. Salem, OR 97302 Phone: (503) 378-4871 Fax: (503) 378-4594 WARRENTON 2021 Highway 101 P.O. Box 967 Warrenton, OR 97146 Phone: (503) 861-3912 Fax: (503) 861-6074 American LegalNet, Inc. www.FormsWorkflow.com