City of Independence, Missouri - Smoking Ordinance Complaint

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Smoking Ordinance Complaint

Establishment Information
Name of Establishment:
Type of Establishment:
Street Address:
ZIP Code:
Phone Number:

Complaint Information
Date of Occurence:	mm/dd/yyyy format
Time of Occurence:	:
Type of Violation: (check all that apply)	Customer Smoking Employee/Owner Smoking No-Smoking sign not posted Ashtrays/Smoking paraphernalia Smoking allowed in no-smoking area Person in charge fails to inform violator(s) to stop smoking Other (please describe below)
Brief description of the violation:

Complainant Information
Name:
Phone Number:
E-Mail Address:

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