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