1. Date(s) of Occurrence (list all dates that apply):
 

2. County in which the violation occurred:
 

3. Name of retailer or reseller:
 

4. Address:
   

   City and Zip Code:
   

   Telephone:
 

   Name of Person:
   

5. Potential Violation (select all that apply):

   Selling flavored nicotine vapor products

   Using fraudulent or misleading statements to sell vapor products

   Advertisements for vapor products within 25 feet of register, food, or visible from outside of building

   Use of images or colors in vapor product ads

   Use of ads that suggest a vapor product is flavored (other than tobacco flavor)

6. Description of the Potential Violation:

7. If known, name of individual(s) who violated the rule: :
   

8. Please describe any steps you took to bring the violation to the attention of the owner/operator of the business:

Complainant's Name:
   

Address:

Telephone: