Store Name:

Store Address (please include the zip code if you know it):


Give a brief explanation as to why you are reporting the store
(i.e., the clerk sold to someone who looks like a kid)

When you saw the purchase:

Who made the sale (description of the seller):

Should you care to receive follow up information after we have investigated this complaint, please give your email address or telephone number here.
Email:   
Your contact information will remain confidential.