Clerk*

Registered Agent/Owner*

Violator Name*

Alias

DOB*

Home Phone

Email

SSN

Operators License Number

Gender*

Male   Female

Race*

White   Black   Hispanic   Am. Indian   Asian

Height*

Weight*

Hair*

Eyes*

Business Name*

Business Address

Business Address*

County*

Violation Date*

Violation Time*

Kentucky Sales Tax Number

Statute*

Charge(s)

Hearing Location

Hearing Date*

Hearing Time*

Violation Details*

Purchaser's DOB*

Purchaser's age

Gender*

Male    Female

Type of Sale*

Over-The-Counter

Type of Product*

Cigarettes    Smokeless    Vape

Type of Outlet*

General Merchant    Convenient Store    Gas Station    Tobacco/Vape Shops    Small Grocery    Convenient/Gas    Drug Store    Other

Enter other type of outlet*

Evidence Held*

Evidence Location*

Witness 1

Address 1

Witness 2

Address 2

First Name* This field is required

Middle Name This field is required

Last Name* This field is required

Phone* This field is required

Email* This field is required

Originating Agency Identitfier (ORI)* This field is required

Badge Number* This field is required

Department Name* This field is required

Job Title* This field is required