Incident Form

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Fields marked with a red asterisk are required. Other fields are optional. The more information you can provide the quicker we can help you.

Reporting as

Bingo Patron

Organization

Select whether you are reporting as a Bingo Patron or Organization.

First Name

Enter your first name.

Last Name

Enter your last name.

Phone Number

Enter your phone number in this format: (555) 555-5555.

Street Address

Enter your street address.

City

Enter your city.

State

Zip Code

Enter a valid ZIP code, such as 70802 or 70802-1234.

Name of Hall

Enter the name of the hall.

Name of Organization

Enter the name of the organization.

Date of Incident

Enter the date of incident.

Witness Information (if any)

Witness Name

Address

Phone Number

Enter the witness phone number in this format: (555) 555-5555.

Witness Name

Address

Phone Number

Enter the witness phone number in this format: (555) 555-5555.

Explain Nature of Complaint or Response

Enter the complaint details.

Signature

Enter your signature.

Date

Enter the signature date.

License Number (organizations only)

Required when reporting as Organization.

Enter the organization license number.

Witness Statement (if any)

Witness Signature

Date Witness Signed

Important Notice

Incident Form

Witness Information (if any)