First Name
Last Name
Address
City
State
Zip
DOB
Gender
Activities you're involved in: * Smoke/ Use TobaccoEnjoy SportsRead MagazinesVolunteer/ Donate Charity
Products you use: * CigarettesVapeChewing TobaccoCigarsLoose TobaccoNone/ Other
Where do you purchase your tobacco products: * Convenience StoreGas StationGrocery StoreTobacco StoreNone/ Other
How often do you use tobacco products: * DailyWeeklyMonthlyOn OccastionDo Not Use
CELL PHONE*
EMAIL*
Yes, I certify that I am 18 years of age or older; and that all the information I provided in this survey is correct. I further certify that I smoke cigarettes and/or cigars and/or use smokeless tobacco products and I would like to receive free samples, coupons and special offers for cigarettes and/or smokeless tobacco products and/or cigars or other communications by US mail and/or e-mail from companies that market tobacco products. Note: By providing my email address, I agree to receive email communications from companies that market tobacco products.
