Applicant Controlling Person Affidavit

Arizona Department of Liquor Licenses and Control 800 W Washington 5th Floor Phoenix AZ 85007-2934 www.azliquor.gov (602) 542-5141 ACT OF VIOLENCE REPORT A.R.S. §4-244(37) %22Act of violence%22 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)) %22Serious act of violence%22 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: (Exactly as it appears on liquor license) License # Name of Business Where Violence Occurred: Physical Address: Street City Hour State Minute Zip 1. Date of this report:____/____/____ Date/Time of incident:____/____/____ _______:_______ AM/PM Report # 2. What law enforcement agency was contacted? 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 a) b) c) (Attach additional sheets if needed) Injury 11/4/14 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 7. Details of incident: x Printed name of person preparing this report Title or position THE CONTENTS OF THIS REPORT ARE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. x Signature of person preparing this report LICENSEE MUST KEEP A COPY OF THIS RECORD FOR TWO YEARS (A.R.S. §4-119) 11/4/14 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com