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DBPR 0110-1 - Alcoholic Beverages and Tobacco Complaint Form


State of Florida
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-1023


If you have any questions or need assistance in completing this form, please contact
the Department of Business and Professional Regulation, Customer Contact Center, at 850-487-1395.


8/22/2017

Section 1 - Establishment Information


Name:
Address:
City:
County (If Florida Address):
State:


Zip Code:
Business Phone (If Known)
License Number (If Known):

Section 2 - Complainant Information (Optional)


Last Name:
First Name:
Middle Name:
Title:
Suffix:
Organization Name
(If representing an organization, please provide the name of the organization):

Contact Information

Primary Business Phone Number:
Primary Home Phone Number:
Primary E-Mail Address:


Does the Complainant want to be contacted?
Yes   No

Section 3 - Details of the Complaint


Details of Complaint:

Contact Person (If Other Than Yourself)

Last Name:
First Name:
Middle Name:
Title:
Suffix:

Mailing Address

Street Address or P.O. Box:
City:
State:
Zip Code:
County (If Florida Address):
Country:

Contact Information

Primary Phone Number:
Primary E-Mail Address:

Private Attorney for Complainant (If Applicable)

Last Name:
First Name:
Middle Name:
Title:
Suffix:

Mailing Address

Street Address or P.O. Box:
City:
State:
Zip Code (+4 Optional):
County (If Florida Address):
Country:

Contact Information

Primary Phone Number:
Primary E-Mail Address:

Subject of Complaint

Last Name:
First Name:
Middle Name:
Title:
Suffix:
Company/Organization:

Mailing Address

Street Address or P.O. Box:
City
State:
Zip Code (+4 Optional):
County (If Florida Address):
Country:

Contact Information

Primary Phone Number
Primary E-Mail Address:

Residence Address (If Different Than Mailing Address)

Street Address or P.O. Box:
City:
State:
Zip Code (+4 Optional):
County (If Florida Address):
Country:

Private Attorney For Subject Of Complaint (If Applicable)

Last Name:
First Name:
Middle Name:
Title:
Suffix:

Mailing Address

Street Address or P.O. Box:
City:
State:
Zip Code (+4 Optional):
County (If Florida Address):
Country:

Contact Information

Primary Phone Number:
Primary E-Mail Address:

Witness (If Applicable)

Last Name:
First Name:
Middle Name:
Title:
Suffix:

Mailing Address

Street Address or P.O. Box:
City:
State:
Zip Code (+4 Optional):
County (If Florida Address):
Country:

Contact Information

Primary Phone Number:
Primary E-Mail Address:

Witness (If Applicable)

Last Name:
First Name:
Middle Name:
Title:
Suffix:

Mailing Address

Street Address or P.O. Box:
City:
State:
Zip Code (+4 Optional):
County (If Florida Address):
Country:

Contact Information

Primary Phone Number:
Primary E-Mail Address:


I affirm that I have provided the above information completely and truthfully to the best of my knowledge