Act Of Violence Report - Arizona Department Of Liquor Licenses And Control Page 2

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7. Details of incident:
x
Printed name of person preparing this report
Title or position
THE CONTENTS OF THIS REPORT ARE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
x
Signature of person preparing this report
LICENSEE MUST KEEP A COPY OF THIS RECORD FOR TWO YEARS (A.R.S. §4-119)
11/4/14
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