|
Once you are verified as a smokeless tobacco consumer 21 or older, you will be eligible to receive coupons, special offers and information delivered right to your door via U.S. Mail or email.
|
| | |
|
Title
required
|
|
| | |
|
First Name
|
required
|
| | |
|
Middle Initial
|
|
| | |
|
Last Name
|
required
|
| | |
|
Current Address
|
required
|
| | |
|
City
|
required
|
| | |
|
State
|
required
|
| | |
|
ZIP CODE
|
required
|
| | |
|
During the past 2 years, have you lived at another address?
required |
|
| | |
|
|
|
| | |
|
Previous Address
|
required
|
| | |
|
City
|
required
|
| | |
|
State
|
required
|
| | |
|
ZIP CODE
|
|
|
|
Why we ask
|
| | |
|
Date of Birth
|
|
/ |
|
/ |
|
|
| | |
|
Phone Number
|
|
|
By providing my e-mail address, I agree to receive e-mail communications from companies that market tobacco products. Please note, to complete your e-mail registration, you will be sent an email asking you to confirm this request.
|
| | |
|
E-Mail Address
|
required
|
| | |
|
Confirm E-mail Address
|
required
|
| | |
|
Please indicate which other tobacco products you currently use (if any):
|
| |
|
| | |
|
Please select your regular brand of smokeless tobacco, that is, the brand you buy most often.
|
| |
required
|
| | |
|
What is the style of your regular brand?
required
|
|
| | |
|
What flavor is your regular brand?
required
|
|
| | |
|
How many cans of moist smokeless tobacco do you typically purchase per week?
|
| |
required
|
| | |
|
Out of the last 10 times you bought smokeless tobacco, how many times have you bought your regular brand?
|
| |
required
|
| | |
|
Do you have an alternate brand that you occasionally buy?
required
|
|
| | |
|
Which alternate brand do you buy most often?
|
required
|
| | |
|
Please indicate the reasons why you might buy an alternate brand.
required
|
|
| | |
|
How do you usually purchase these products?
required
|
|
| | |
|
How much do you agree or disagree with the following statements about when you purchase smokeless tobacco? required
|
|
|
|
Electronic Signature:
Pursuant to the Federal Electronic Signatures in Global and National Commerce Act and applicable state laws, I consent to use and reliance on my electronic signature to verify the information that I have provided herein. I certify that I am a smokeless tobacco consumer 21 years of age or older, and would like to view and receive communications from companies that market tobacco products.
Enter your first and last name below to indicate agreementmake sure you enter them exactly as you entered them above.
|
| | |
|
First Name
|
required
|
| | |
|
Last Name
|
required
|
| | |
| |
| |
| |
| | |
| |
| |
| | |
| |