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• a vIWWI 0 I VJI I.l 464 <br /> QUIK STOP MARKETS, I� <br /> In-Store Incident Report Store No. <br /> 1 ' tructions;l Complete type of incident report and appropriate sub-section listed below, <br /> Clerk must complete this form at the time of incident, sign and date it. <br /> Store Manager must approve and sign. This form is to be attached to your <br /> cash report and sent into the office for *proper distribution. <br /> Complete Type of Incident (Check one) Gas Dr�•Wa 41. —Shoplifting Customer <br /> In Full S(' <<< Compliant <br /> Detail <br /> Employee on duty/Name; a.g _['� ^L c, Time• -E AM3 M :49. Da; <br /> Police Notified: Yes No Police Report Number: <br /> Officer's Name; Badge ; <br /> Give Complete Details: t,Lj Ca^ o 4.,,, k, ,� A� � .ar .!: '�►+ Es <br /> -4,._4 - - <br /> C 4 1 iJ Ct n)d 1-4 -4 c( <br /> Gasoline Was Intercom on: Yes No Was Intercom used: Yes No <br /> Drive-off p Was Console off prior to Salle authorization; <br /> Yes <br /> Report No Amount/Loss. <br /> Give Description of Person: <br /> Description of vehicle; License #: <br /> Name of: Phone #: <br /> Description of Merchandise Involved: Est. Value$ <br /> Shoplifting Description of Offender: Sex Race Height Weight <br /> Report <br /> Approx. Age: Color of Hair Eyes Build <br /> Was Defender Apprehended? Yes No <br /> Name of Defender; Phone # <br /> Address: Age: —'— <br /> Parents Address( if minor) : <br /> Name of Witness(s) Phone N <br /> Customer Name: Phone M <br /> Compliant <br /> Report Adaress ; <br /> Nature of Complaint: <br /> - Sicnsture of Cier<: Date, J / <br /> Stgnat.;r-, of Store Mgn. : Date: I / <br /> Note: acco:n::_ C *,his report is turned over to the Area Rep, OSM-081 <br /> r <br /> �•�ea Rai. ;�3 ���?r s:,a for your torments and follow tnrougb 11/85 <br />