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MBC Presentations * 21100 Excelsior Blvd. * Excelsior, MN 55331 <br /> <br />PARTICIPANT: REPORT (Page Four) <br /> <br />INCIDENT REPORTING FORM (Confidential) <br /> <br />To the Attorney Representing: <br /> (Name of company/licensee) <br />From: ........... <br /> (Employee(s) involved) <br />Date of incident: . <br /> <br />CUSTOMER: Information about or description of whom was refused service or sale <br />(name, credit card #, license #, auto plate #, model car, associates, other identifying info.): <br /> <br />INCIDENT: <br /> <br />Information about or description of what happened: <br /> <br />WHEN did customer arrive? .... <br />WHEN did customer leave? . <br /> <br />Did customer drive? Yes~ <br />Was incident reported to management? Yes~ <br />Was incident reported to police? Yes.~ <br />Follow up information (Use back if necessary): <br /> <br />No . Don't know . <br />,No . <br />No _ Don't know , <br /> <br /> DUE DILIGENCE IN I. D. CHECKING DOCUMENTATION <br /> To be completed by the person being questioned. <br /> I am at least twenty-one years of age. <br /> I know I am subject to arrest if! misrepresent my age in order to obtain alcohol. <br /> <br />Driver's License #:. State: <br /> Name (Print): <br /> <br /> Address: <br /> <br /> City, State, Zip: <br /> <br />MY AGE TODAY IS: ...... <br /> Signature Date <br /> To the best of my knowledge, information above is accurate <br /> <br /> Employee Signature: . Date Signed: <br /> Signature of Manager:~ Date Received: <br /> <br />Phone 612-470-9025 * Toll flee 800-242-2499 * FAX 612-470-9019 <br /> <br /> <br />