Sample Request Form

Sample Request

Please complete this form and provide a readable photocopy of you picture ID verifying your age is over 21.  Cigarettes samples will not be sent without complete information and copy of ID.
BE SURE TO INCLUDE PHOTO ID

NAME________________________________PHONE_______________________

 ADDRESS_____________________________FAX__________________________

 ____________________________________EMAIL__________________________

CITY________________________STATE______________ZIP________________
The following samples are available.  Please choose one by brand and flavor or we can select a sample for you based on what you are currently smoking.
CIRCLE YOUR SELECTION CAREFULLY
Brand per Carton Size / Package Flavors
Broncos 12.95 King / Box Full Flavor / Light / Menthol / Menthol Light / Ultra Light
                        100’s / Soft Full Flavor / Light / Ultra Light / Menthol / Menthol Light
Natives 9.95 King / Soft Full Flavor / Light / Ultra Light / Menthol / Menthol Light
NY Seneca 10.95 King /Box Full Flavor / Light / Ultra Light / Menthol / Menthol Light /Non-filter
                             100’s / Soft Full Flavor / Light/ Ultra Light / Menthol / Menthol Light / Menthol    
                                       Ultra Light
GT One 10.95 King / Soft Full Flavor / Light / Ultra Light / Menthol / Medium / menthol Light
                         100’s /Soft Full Flavor / Light / Ultra Light / Menthol / Medium / Menthol Light
Cowboys 13.95 King /100’s/ Soft Flavor / Light / Menthol
                          King / Box Full Flavor / Light / Menthol
Opal 120’s 14.95 120’s /Full Flavor / Light / Ultra Light / Menthol / Menthol Light
Please indicate what brand, size and flavor you are currently smoking.
Brand_______________________ King/ 100’s Flavor______________
please send me the sample I have chosen above or select one for me.  I am over the age of 21 and have included proof of such with this request.
Signature___________________________Date_________________DOB______________
How did you hear about OTDirect? _____Classified ______ Magazine _____Internet_____
What is most important to you? _____ Flavor _____ Price _____Both
Have you purchased cigarettes over the internet or thought the mail before ___ Yes ___No
If yes, when was the last time? ___ 1 Week ___ 1 Month ___ 3 Months ___6 Months
If you know anyone who would like a sample, please photocopy this and pass it along.
Mail this request and copy of ID to OTDirect - Sovereign Seneca Territory
OR Fax to (716)  337- 0156   P. O. Box 246 – Grant, NY 14027

If you have any questions, please contact  
Judy DeGroot  Ref#  31154
                                                                   Email cigarettessave@aol.com
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