Notification of Irregularities and Criminal Activity Form
DCR License Record Number:
Legal Business Name:
DBA (Doing Business As):
Address of the Cannabis Business:
Date and Time of Incident:
Name of the Local Law Enforcement Agency notified (e.g., LAPD or Sheriff’s Department), if applicable:
Provide a brief description of the incident and include any additional information, if needed:
Please upload any related documents here, including a copy of the police report if available:
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