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Business COVID Non-Compliance Report Form

2. Porter County Business COVID Non-Compliance Report Form

4. This form is to report non-compliance with general requirments for Porter County businesses and entities and/or the special requirements for restaurants, bars, taverns, nightclubs and other establishments providing in-person food.

6. Please be sure to read the requirements for businesses at this link BEFORE you submit this form.
   READ REQUIREMENTS HERE

8. Your Contact Information
   This information is required. We will only contact you if we have further questions about your report.

   This information is required. We will only contact you if we have further questions about your report.

10. First Name*

11. Last Name*

13. Your Email Address*

14. Your Daytime Phone Number*

16. How would you prefer that we contact you if we have further questions?*

    1. By Email

    1. By Phone

    1. Either

18. Business Information
    Please provide the following information about the business you are reporting.

    Please provide the following information about the business you are reporting.

20. Business Name*

22. Business Street Address*

23. City*

25. Describe The Non-Compliance Issue(s) You Are Reporting. Please be as specific as possible.*

27. What Date & Time Did You Witness The Non-Compliance Issue(s)?*
    What Date & Time Did You Witness The Non-Compliance Issue(s)?

    What Date & Time Did You Witness The Non-Compliance Issue(s)?

29. All fields in this form REQUIRE an answer. Please be sure to verify that you have answered all questions before you submit this form. You will not be able to submit this form unless all questions are answered.

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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

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