Service Refusal Report - Arizona Department Of Liquor Licenses And Control Page 2
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2How 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:
(attach additional sheet if necessary)
Witness #1: _________________________________________________________________________, __________________________________
First and Last Name
Staff or Independent
Witness #2: _________________________________________________________________________, __________________________________
First and Last Name
Staff or Independent
7. Name of person/persons injured and type of injury:
(attach additional sheet if necessary)
Injury #1: ___________________________________________________________________________, __________________________________
First and Last Name
Type and Location of injury
Injury #2: ___________________________________________________________________________, __________________________________
First and Last Name
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:
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)?
• Were the companions found alternative rides as well?
YES
NO
• 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?
• If they drove away, did you obtain a plate number and call the police?
YES
NO
• 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
Title or position held
________________________________________________________
________________________________________________________
Daytime contact number
Alternate contact number
8/21/2015
Page 2 of 2
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