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<br />. <br /> <br />d- <br /> <br />Loss Control Services Inc <br /> <br />Alcohol Awareness Programs 763-545-5981 <br />Robert Pomplun 1804 Mendelssohn Avenue North Golden Valley, Mn 55427 nS <br /> <br />'w~\e'-l12..jd!y..)o~.I~' I~ ~-, <br />LOSS CONTROL SERVICES VERIFICATION FORM ~ ~1/UVVr~{) <br /> <br />DATE: \;). I I ~ I a...o CAS <br /> <br />TO INSURANCE COMPANIES: <br /> <br />OUR ESTABLISHMENT HAS PARTICIPATED IN THE LOSS CONTROL <br />SERVICES ALCOHOL AWARENESS SEMINAR FOR OUR EMPLOYEES <br />INSTRUCTION IN THE LEGAL AND MORAL RESPONSIBILITIES <br />REGARDING THE SERVICE OF ALCOHOL. OUR AIM IS TO INCREASE <br />THE USE OF DOCUMENTATION OF INCIDENTS AND STRATEGIES USED TO <br />PREVENT THEM, THE INSTRUCTION IN' THIS PROGRAM HAS MADE EACH <br />SERVER AWARE OF HIS/HER INDIVIDUAL LIABILITY IN THE SERV7CE <br />OF ALCOHOL, COMPLIANCE WITH THE GOIDELINES SET FORTH IN THE <br />PROGRAM WiLL HELP REDUCE THE RISKS OF THE SERVICE OF ALCOHOL <br />TO CUSTOMERS AND THE COMMUNITY, <br /> <br />. SEMINAR LOCATION: -TRlI '-'-.~. 'r'f /.....ed-~DJ <br /> <br />SEMINAR DATE: Sur-d1A--1 l~ ,-Dee- (2 ,~, ~ <br />DAY MONTH DATE YEAR <br /> <br />FROM 10 to 0 A,M, /Q TO I: De') A.~ <br /> <br />A TOTAL OF 0 EMPLOYEES PARTICIPATED IN THE <br />SEMINAR FOR A TOTAL OF PERCENT OF TOTAL HOURS <br />EMPLOYEES WORK THAT SERVE ALCOHOL IN OUR ESTABLISHMENT (SEE <br />ATTACHED VERIFICATION FORMS) . <br /> <br />WHEN NEW ALCOHOL SERVERS ARE HIRED WE WILL TRAIN THEM <br />THROUGH THE USE OF MATERIALS PRESENTED IN THE SEMINAR. <br /> <br />LIST OF EMPLOYEES ATTENDING THE SEMINAR (SEE ATTACHED LIST) : <br /> <br />I CERTIFY THE STATEMENTS ARE CORRECT <br /> <br /> <br />. <br /> <br /> <br />INSURANCE COMPANY COpy <br />