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. DBPR 0110-1 Alcoholic Beverages and Tobacco Complaint Form
.
. State of Florida Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-1023
. If you have any questions or need assistance in completing this form, please contact the Department of Business and Professional Regulation, Customer Contact Center, at
(850) 487-1395.
.
SECTION 2 - COMPLAINANT INFORMATION (Optional)
SECTION 1 - ESTABLISHMENT INFORMATION
Name
Address
City
County
State
Zip Code
Business Phone (if known)
License Number (if known)
Last Name
First
Middle
Title
Suffix
Organization Name (if representing an organization, please provide the name of the organization)
CONTACT INFORMATION
Primary Business Phone Number
Primary Home Phone Number
Primary E-Mail Address
Does the Complainant want to be contacted?
Yes No
SECTION 3 - DETAILS OF THE COMPLAINT
.