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:
_______________________________________________________________________________________________
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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
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Did a police officer attend the incident: ⃝ Yes
⃝ No
Name of police officer/badge no. ____________________________________________________________________
PTO
Details of the incident and preceding events:
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Any additional information
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Full name of Licensee or Responsible Person and Date
Version 2, February 2013