Act Of Violence 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
ACT OF VIOLENCE REPORT
A.R.S. §4-244(37)
"Act of violence" means an incident consisting of a riot, a brawl or a disturbance, in which bodily injuries are sustained by any person
and such injuries would be obvious to a reasonable person, or tumultuous conduct of sufficient intensity as to require the intervention
of a peace officer to restore normal order, or an incident in which a weapon is brandished, displayed or used. (A.R.S. §4-101(1))
“Serious act of violence” means an incident consisting of a riot, a brawl, or a disturbance in which a serious injury causes death or
critical injury of a person and such injuries would be obvious to a reasonable person. (A.R.S 4-210(A)(14))
It is unlawful for a licensee to fail to report an occurrence of an act of violence to either the department or a law enforcement
agency. (A.R.S. §4-244(37))
It is unlawful for a licensee to fail to report a serious act of violence to either the department or a local law enforcement agency.
(A.R.S 4-210(A)(15))
Licensee/Agent Name:
License #
(Exactly as it appears on liquor license)
Name of Business Where Violence Occurred:
Physical Address:
Street
City
State
Zip
1. Date of this report:____/____/____
Date/Time of incident:____/____/____ _______:_______ AM/PM
Hour
Minute
2. What law enforcement agency was contacted?
Report #
Who called for law enforcement assistance?
Was an arrest made?
Yes
No
3. What emergency services were requested?
Who called for these services?
4. Was a weapon used or displayed?
Yes
No If yes, what type of weapon?
5. Identify or describe participants:
6. Name(s) of person(s) injured and type of injuries:
Person
Injury
a)
b)
c)
(Attach additional sheets if needed)
11/4/14
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