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LEU-37 8/2014 Explanation of Concern Please give a detailed description including dates, times, names, activity of concern, frequency and any other information. (Continued on the reverse) Thank you for taking the time to register your concern. The Montana Department of Revenue, Liquor Control Division takes public concerns seriously. Working together will make a difference in enforcing Montana liquor laws and administrative rules that ultimately impact the safety of our communities. Further investigation may be necessary prior to any Department of Revenue action. Name: E-mail address: Phone Number: Mailing Address: I am (check one) A customer Connected to the alcohol industry Concerned community member Please note that choosing to remain anonymous can negatively impact the ability to effectively investigate and address your concern and could result in no action regarding your concern. Investigators need your contact information so they may follow up or obtain more information. Once the form is completed, you may: Mail to: Liquor Control Division, PO Box 1712, Helena, Montana, 59624 Fax to: (406) 444-0718 E-mail to: [EMAIL REDACTED] Or visit us at: Liquor Warehouse, 2517 Airport Road, Helena, Montana, 59601 NOTIFICATION OF CITIZEN CONCERN OF A POSSIBLE LIQUOR LAW VIOLATION Please check the following box that indicates a potential liquor law violation or concern and explain below: Over-service to an intoxicated person Sale to an underage person Disorderly licensed premises Sales/Service/Consumption on a licensed premises between 2 am and 8 am Other Name of Licensed Premise of Concern Street Address of Licensed Premise City Name of Individual of Concern (bartender, server/seller, owner, etc.) MONTANA DEPARTMENT OF REVENUE Liquor Control Division ---PAGE BREAK--- LEU-37 8/2014