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 Year20232024202520262027 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 Year192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 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.
