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2. First Name
3. Last Name
5. Address1
7. City
8. State
9. Zip
11. Date/Time submitted
    Date/Time submitted

    Date/Time submitted
12. Phone number
13. email address
15. Name of business/suspect
    Place name of business selling alcohol to minors or suspect giving alcohol to minor.
17. Describe alcohol violations/problems
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19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

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