Use of Force Register Regulation 20(d) of the Liquor Licensing Regulations 2012 This register must be completed as soon as reasonably practicable after any incident involving the use of force to prevent entry to or remove a person from the premises. All entries in the Register must be retained by the licensee for at least one year following the incident. This register must be readily available for inspection or copying by an authorised officer (as defined by Section 122 of the Act). Name and address of premises:_____________________________________________________________________ Date of incident:____ /____ /_____
Time of incident:_______ am or pm
Nature of incident:
⃝ removal from premises
⃝ prevention of entry
Did the incident involve a minor? ⃝ No
⃝ yes
Responsible person on duty at time of incident; Full name :________________________________________
Badge No:___________________________________
Authorised persons (s) who removed the person (s) or prevented entry of the person (s): Full name :________________________________________
Badge No:___________________________________
Full name: ________________________________________
Badge No:____________________________________
Grounds for preventing person (s) from entering, or removing person (s) from, the premises: _______________________________________________________________________________________________ continue over page if necessary Details of person (s) prevented from entering, or removed from the premises (if known): Name:________________________________________
Name: ________________________________________
Address:_______________________________________
Address: ______________________________________
Email address__________________________________
Email address__________________________________
Date of birth:____ /____ / ____
Date of birth: ____ / ____ / ____
Details of any witness(es) to the incident (if known): Name: ______________________________________
Name: ______________________________________
Address: ____________________________________
Address: ____________________________________
Date of birth: ____ / ____ / ____
Date of birth: ____ / ____ / ____
Details of injuries (if any) sustained by any person as a result of the incident: Name: _______________________________________
Injury: _________________________________________
Name:_______________________________________
Injury:__________________________________________ PTO