**Items in BOLD are required**
Date of Violation: **
Time of Violation:
County: ***You MUST choose a county*** Athens-Clarke Barrow Elbert Greene Jackson Madison Morgan Oconee Oglethorpe Walton PLEASE NOTE: This form should only be used for the counties (listed above) in the Northeast Health District, surrounding Athens, Georgia. Submissions from outside of this service area can not be honored.
Establishment Name: **
Establishment Location: (address, street, shopping center etc)
Is this a: BAR RESTAURANT OTHER BUSINESS
Description of Incident:**
Were ashtrays present? YES NO UNSURE Were smokers using cups of water as an ashtray? YES NO UNSURE
Was there a NO SMOKING sign present? YES NO UNSURE
Your Email: (optional) Used only if additional information is required. It will not be added to a mailing list, nor will it be shared with outside parties, except as required in reporting violations or to obtain additional information.
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Why?
Please click Submit Form below to send your complaint. THANK YOU!
