Paperwork Reduction Act Statement

Form Approved: OMB NO. 0910-0716

Expiration Date: 07/31/2017

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  1. Potential Violation
    Information
  2. Who Potentially
    Violated
  3. Contact Information
  4. Review and Submit
Potential Violation Information
* Required field
State
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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