Tobacco Violation Complaint Form

Please fill out this form to report a violation. Although your contact information is not required, we highly recommend that you provide us with this information. Often times we may need additional information to respond to your complaint as efficiently and effectively as possible. Please note that all personal information that you provide is kept in confidence and will only be used in relation to this complaint.

Thank you for taking the time to report this violation!

Contact Name

Contact Phone #

Contact E-mail

Complaint Information:

Type of Violation:  Public Place Work Place

Date Occurred:

Name of business and location:

Describe what occurred
(e.g. people at bar were smoking in presence of bartender):

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