Today's date:

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2011 2012 2013 2014 2015

Date violation was witnessed:

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2011 2012 2013 2014 2015

Approximate time witnessed:

01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 45 AM PM

Business name:

Business address:

Street:

City: Bromley Covington Crescent Springs Crestview Hills Edgewood Elsmere Erlanger Fairview Fort Mitchell Fort Wright Independence Kenton Vale Lakeside Park Latonia Lakes Ludlow Park Hills Ryland Heights Taylor Mill Villa Hills Unincorpated Kenton County Walton

Note: Your contact info is optional. Complaints may be submitted anonymously.

Your first name:  

Your last name:

Your address:

Street:

City: , State: Kentucky Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washingtion Virginia Washington West Virginia Wisconsin Wyoming

Phone number, including area code: ()

Type of smoking violation reported--please select all that apply. Hold down the control key to select more than one:

Customer smoking witnessed in prohibited area Employee smoking witnessed in prohibited area Signage does not meet requirements Ashtrays present inside

Please describe the nature of the problem (Note: Limit 250 characters):