Address

City State Zip

Phone: Email:

Complaint Form

Establishment

Address

City State Zip

Phone: Email:

Owner or Manager

Please describe your complaint and/or check boxes below:
How many people were smoking in non-smoking area
Were any employees/patrons smoking inside the establishment?
Were any employees/patrons smoking in other non-smoking areas
(such as within 20 feet of doors and windows?)
Were appropriate No Smoking signs posted? cccccccYes No
Was the owner present while people were smoking? Yes No

Please describe your observations: