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                       SAMPLE REQUEST FORM
Turning the Tobacco Industry Around       To print this form, use the "Print" button on your browser
PLEASE COMPLETE AND PROVIDE A READABLE PHOTOCOPY OF YOUR PICTURE ID
VERIFYING YOUR AGE IS OVER 21.
CIGARETTES WILL NOT BE SENT WITHOUT COMPLETE INFORMATION AND COPY OF ID

NAME ______________________________________    PHONE_____________________________

ADDRESS____________________________________   FAX ________________________________

                  ___________________________________   EMAIL ______________________________

CITY  _______________________________  STATE ________      ZIP CODE __________________

The following samples are available. Please choose only one brand by flavor
or we can select a sample for you based on what you are currently smoking.
CYRCLE YOUR SELECTION CAREFULLY
     BRAND            Per Carton    Size/Package                                           Flavors
NATIVES           9.95      King/100/soft      Full /Light/Ultra Light/Menthol/MentholLight
NIAGRA          12.45      King/Soft             Full /Light/Menthol/Menthol Light
ROGER            13.95      King/Box            Full /Light/Menthol
ROGER            13.95      100/Box              Full /Light/Ultra Light/Menthol/Menthol Light
NY SENECA    10.95      King/Box           Full /Light/Ultra Light/Menthol/MenthLight/Non Filter
NY SENECA    10.95     100/Soft               Full /Light/Ultra Light/Menthol/Menthol Light
GT ONE           10.95      King/Soft             Full /Light/Ultra Light/Menthol/Medium/Non Filter
GT ONE           10.95      100/Soft               Full /Light/Ultra Light/Menthol/Medium
Please Indicate what brand, size and flavor you are currently smoking
Brand_________________      King or 100's                 Flavor ____________________________
Please send me the sample I have chosen above or select one for me. My signature below certifies that I am over the age of 21 and have included proof of such with this request

Signature _______________________________ Date _______________  DOB ____________
            If you know anyone who would like a sample, please photo copy this and pass it along!!!  OVER 21 ONLY
 

 Please mail this request and copy of ID to:

OTDirect - Soverign Seneca Territory
P.O. Box 246 - Brant, NY  14027

How did you hear about OTDirect?  ____Classified  ___Magazine __  Internet  __ Friend  ___ Other
What is most important to you?   ____ Flavor    ___ Price   ___ Both
Have you purchased cigarettes over the internet or thru the mail before?  ___Yes    ___No
            If yes, when was the last time?  ___ 1 Week    ___1 Month   ___3 Months   ___ 6 Months

If you have any questions, please contact 
Don Searles - dopasea@email.com  Ref#-6378,
or visit my web site at   http://www.otdirect.com/?6378
   SAMPLES SENT!