Paperwork Reduction Act Statement

Form Approved: OMB NO. 0910-0716

Expiration Date: 07/31/2017

  1. Potential Violation
  2. Who Potentially
  3. Contact Information
  4. Review and Submit
Potential Violation Information
* Required field
Type of Product
Tobacco Brand
Potential Violation Type* (Check all that apply)

Type of Potentially Violative Promotional Materials* (Check all that apply)

Description of Potential Violation

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