Service Refusal Report - Arizona Department Of Liquor Licenses And Control
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2Arizona Department of Liquor Licenses and Control
800 W Washington 5th Floor
Phoenix, AZ 85007-2934
(602) 542-5141
SERVICE REFUSAL REPORT
A.R.S. §4-244.14.
For a licensee or other person to serve, sell or furnish spirituous liquor to a disorderly or obviously intoxicated person, or for
a licensee or employee of the licensee to allow or permit a disorderly or obviously intoxicated person to come into or remain on or about
the premises, except that a licensee or an employee of the licensee may allow an obviously intoxicated person to remain on the premises
for a period of time of not to exceed thirty minutes after the state of obvious intoxication is known or should be known to the licensee in
order that a non-intoxicated person may transport the obviously intoxicated person from the premises. For the purposes of this section,
"obviously intoxicated" means inebriated to the extent that a person's physical faculties are substantially impaired and the impairment is
shown by significantly uncoordinated physical action or significant physical dysfunction that would have been obvious to a reasonable
person.
1. Date of this report: __________/______/________
Month
Day
Year
Date/Time of incident: __________/______/_______ _____:_____
Month
Day
Year
Hour
Minute (approx)
Name of liquor licensed establishment: _________________________________________________________________________________
Physical address of licensed establishment: ___________________________________________________, ______________, __________
Street Address
City
Zip
Phone number of liquor licensed establishment: (________) __________-________________
2. What police authorities were summoned? ____________________________________________________________________________
Police Report #: _______________________________________
Who called police?
_____________________________________________________________________________________
First and Last Name
Was an arrest made by the police?
YES
NO
Who was arrested? ____________________________________________________________________________________________________
3. What emergency services were summoned? _________________________________________________________________________
Who called for these services?
___________________________________________________________________________
First and Last Name
4. How many drinks was the patron served throughout his/her visit? ______________________
5. Identify or describe participants/intoxicated persons using a copy of their ID or information recorded from their ID. Provide
their cell phone or daytime contact number.
Participant #1: _______________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Describe this person’s appearance of intoxication:
a
b
c
8/21/2015
Page 1 of 2
Individuals requiring ADA accommodations please call (602)542-9027
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