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/MediumPlease 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
