Please Select * Selling tobacco to a person under 19 years old Selling E-Cigarettes to a person under 19 years old Supplying tobacco to a person under 19 years old Supplying E-Cigarettes to a person under 19 years old Your Details Full Name * Position/Designation Phone Number * Description of Incident Date of Offence * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Time of Offence * Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm School Name * Address * Details Occurrence details and exact location where alleged offence occurred Person Selling or Supplying Tobacco or E-Cigarettes Full Name * Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Address Parent/Guardian Name (if student is under 16 years) Parent/Guardian Address (if student is under 16 years) Witnesses 1) Witness - Full Name 2) Witness - Full Name By submitting this form, I testify all information submitted is true and I am aware that I may be required to attend a Provincial Court to testify regarding this offence.
