Use of Force Register

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

2 Did a police officer attend the incident: ⃝ Yes

⃝ No

Name of police officer/badge no.____________________________________________________________________ PTO Details of the incident and preceding events:

________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Any additional information

________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

________________________________________________________________________________________________ Full name of Licensee or Responsible Person and Date

Version 2, February 2013