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 Year20212022202320242025 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 Year192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 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.
