Surname:
Organisation/Company:
Contact phone:
Postal address:
Post code:
Email address:
Yes
No
Please use this form to tell us about incidents of alcohol-related crime or disorder that you have witnessed
in or around a current alcohol ban area. Please use additional forms if you would like to tell us about
incidents happening in another current alcohol ban area.
1.
Where did the incident specifically happen? (Please name the current alcohol ban area; for
example Victoria Park, town centre)
2.
Where (in the above location) did the incident happen? (for example: northern end of the park
under the trees, in the car park, near the playground etc)
3.
4.
What makes you think that the incident described above was related to alcohol?
Please provide any evidence that you may have to support this.
5.
Can you recall the approximate date/s this incident occurred and how often? (Month/year)
For example month/year or was this during a specific holiday (Christmas or Easter etc)
6.
7.
8.
daily
weekly
monthly
yearly
Other than an alcohol ban what else could be done to prevent this type of incident from
happening at this location?
(for example better lighting, locked gates etc)
The information provided in this form is a true and accurate reflection of the alcohol-related crime or
disorder experienced by myself (or the organisation I am submitting this on behalf of).
Signature:
Date:
Thank you for providing this additional evidence for the council to consider.
Your checklist:
1. Have you included your full name and postal and/or email address?
2. Have you attached any additional pages or supporting documents?
3. Would you like to be updated on the outcome?
All personal information that you provide in your feedback will be held and protected by Auckland Council in accordance with our privacy policy (available at
www.aucklandcouncil.govt.nz/privacy and at our libraries and service centres) and with the Privacy Act 1993.
Our privacy policy explains how we may use and share your personal information in relation to any interaction you have with the council, and how you can access and correct that
information. We recommend you familiarise yourself with this policy.