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D-305305510
812497164
785746
Bruce Hatfield
Consumer Relations
309 Clinton St
Winston-Salem, N. C. 27102
Binghamton, NY 13905-2052
Thank you for contacting us. As part of our continued efforts to stop underage smoking, we verify that every smoker on our
mailing list is 21 years of age or older.
In order to be added to our active mailing list and to be eligible to receive future mailings, please complete this form and
include a copy of an official identification that contains your name. current address and date of birth (driver's license, sporting
license, MEDICAID Voucher or State ID).
If you have any questions about filling out this form, please call 1-800-777-2695. We're open Monday through Friday from
8:00 a.m. to 6:00 p.m. (EST).
The name, street address, city, and state on your official identification MUST MATCH the name, street address,
city, and state shown above or as corrected below on this Age Verification Form.
.If the ID does not match the address where you are to receive mailings, we will be unable to process the Age
Verification Form.
STEP 1: Check to make sure the mailing address above is correct. Print any corrections in the box below on the right. Any
corrections must match your ID.
NOTE: The address on your
Please print corrections below:
official ID must match the
BRUCE
Name
HATfield
address where you will receive
mailings or we will be unable
30 9
clinton ste
o process the Age
Street Address
Verification Form
Binghamton My 13985"
City/State/Zip Code
STEP 2: Your signature and date of birth are
STEP 3; Attach a copy of your identification.
required to determine your eligibility.
What is your Birthdate? /2 ,54
(REQUIRED
(month) (day) (year)
* *
Today's Date?
81 101 00
NEW YORK STATE
ID:210 818 616
(month) (day) (year)
LEARNER PERMIT
DOB: 05-02-54
I certify that I am a smoker; I am 21 years of age or older; and that
I want to receive offers, premiums, coupons, or cigarettes that may
HATFIELD, BRUCE, T
309 CLINTON ST
be sent to me in the mail. I understand that giving false information in
BINGHAMTON
order to accept these offers may constitute a violation of law.
13905 :
Signature S. . ROCK
SEXM EYES! BR HT: 6-01 CLASS D ;
END:
AESTI
(REQUIRED) (first)
(middle injal)
(last
FSI
ISSUED: 08-26-00 EXPIRES. 05 02-05
What is your usual brand of cigarettes? MORAL 150 45
54816040
STEP 4: Send form and copy of ID in the enclosed self-addressed envelope, or mail to:
Atto: Dept. NYFSI, Consumer Relations, PO Box 2959, Winston-Salem, NC 27102
Offer Restricted to Smokers 21 Years of Age or Older.
We respect the privacy of our smokers. We do not sell the names on our lists to anyone.
"We work for smokers."
52272 2759
Source: https://www.industrydocuments.ucsf.edu/docs/txpn0095

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