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U.S. Department of Health and Human Services

Potential Tobacco Product Violations Reporting - Form FDA 3779

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Form Approved: OMB NO. 0910-0716
Expiration Date: 07/31/2014

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Potential Violation Information


Please correct all errors listed below:






200 character limit


*Potential Violation Type

Check all that apply


*Type of Potentially Violative Promotional Materials

Check all that apply


1000 character limit


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