e.
FOR·SMOKERS AGE 21 AND OVER.
nMr.
n Ms. _
nMrs.
r 1 Mole
_ r 1 Female
MI
hrst
Lost
Address Apt.
•
City State __ Zip " Phone-,-( -'-- _
By'responding to the following survey and signing below, I certify that I am a cigarette
smoker 21 years of age or older. I am also willing to receive free samples of cigarettes
and incentive items in the mail, subject to applicable state and federollaw.
SIGNATURE BIRTHDATE
(required) (required) / /
- Moo'" Day '*'0,
hee • I' •• 0Ihw good unlll Jonuary 31, 1993 Please allow 8 to 10 weeks !of delIvery Only manufaclurer's warranly
applies Not responSIble lor losl,late, rmsdireoed. mu1llateQ or postoqe-doe mall Offer good only In USA Consumer;Sur.oey
Assoctates Sunglosses offer IS lImIted 10 one per person regardless of the number 01 surveys completed II may be necessary 10
subslll� 0 dlfferenl pOlr 01 sunglasses II your selechon IS nol ovodoble Your sunglasses are not returnable lor e.chonge VoId
where otn-lse prohIbIted, ioxed or licensed Offer lImIted 10 smokers 21 years Of oge or older
1992 Consumer SuNev AsSOCIates. New 'tor'k
1. What is your regular brand of cigareftes
that is, the brond you smoke most often?
(!>fond nomel
2. Is your regular brand ... ? (Check one.)
r I Regular I King Size, n 100's or n 120's
11s your regular brand ... ? (Check one.)
ri Menthol or n Non-Menthol
4. Is your regular brand ... ? (Check one.)
n Filter or n Non-Filter
� Is your regular brand ... ? (Check one.)
n Lowest/1 m9.:.' tor n Ultra/Extra Low Tor
n Light/Mild n Medium n Full Flavor-
.. Do you usually buy it by the ... ?
n Pack n Carton n Both Ways
7. What, if any, was your previous brand?
l!>fond nomel
L Which of the following best descnbes you?
(Check one in each column.)
r I Nrican-American rl Professional
r 1 American Indian r 1 Self-employed
nAsion r I Homemaker
[l Caucasian rl Skilled Labor
n Hispanic ' n Civil Service
n 11 _
Other Other
- •• Are there other smokers in your household, 21
years of age or older, who are willing to receive
free samples of cigarettes and incentive items in
the mail� Please print full names and birthdates.
Forst Nome
MI
lost
Br,thdote
MI
FIt,t Nome
lost
Br,thdote
MGZ2