Illinois Department Of Public Health - Smoke-Fee Illinois Act Complaint Form Page 2

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STEP 2
Complaint Information
Sufficient information, including the business name and address, must be provided in order for your
complaint to be addressed.
Type of business*
Restaurant
Bowling Alley
Bar/Nightclub
Hotel/Motel
Office Building
Public or State Owned Vehicle
Retail Store
Health Care Facility
Commercial Establishment
Gaming Facility
Private Club
Other (please specify)
Shopping Mall
_________________________
Business Name* ___________________________________________________________________
(or place of violation)
Street Address of Violation* __________________________________________________________
(or cross street address if exact street address is unknown)
City*__________________________________________________ ZIP Code__________________
County* __________________________________________________________________________
Phone Number of Business (______)__________________________________________________
Area Code
Business Owner’s Name ____________________________________________________________
(if known)

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