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Offers and Mailing List restricted to smokers 21 years or older.

I certify that I am a smoker; that I am 21 years of age or older; and that I want to receive offers, premiums, coupons, or cigarettes that I may purchase or that may be sent to me for testing and/or evaluation purposes.  I understand that giving false information in order to accept these offers may constitute a violation of law.

By typing your name in this box, you agree that this will represent your signature for certifying your age.

Your Date of Birth:

 

First Name
 Middle Initial
Last Name
 Suffix (optional)
Address - Line 1
Address - Line 2
City
 State
 Zip

E-mail Address:

Area Code and Phone Number: () -

1. What is your Usual Brand of cigarettes (that is, the one brand you smoke most often)?

2. Your Usual Brand is:

Non-Menthol Menthol

3. Your Usual Brand is:

Full Flavor Medium
Lights Ultra Lights

4. Your Usual Brand is:

Kings/85s 100s 120s

5. Out of the last TEN times you bought cigarettes, how many times did you purchase your Usual Brand?

6. When your Usual Brand is not available, what ONE other brand of cigarettes do you smoke most often?

7. When you purchase cigarettes, do you usually buy them by the:

Pack Carton