CT Cigarette Retailer | Underage Prevention Certification

First Name *

Last Name *

Email Address *

Confirm Email Address *

Are you taking this training because you or your store failed a tobacco or e-cigarette inspection? *

Yes No

Business Name *

Business Entity/Owner *

Business Address *

Business Address 2

Business City *

Business Zip Code *

Is the business name and address above correct? *

Yes No

Daytime Phone *

What is your job title? *

Please specify *

Your Gender *

Male Female Other I choose not to answer

Are You Hispanic or Latino? *

Yes No I choose not to answer

Race (please check all that apply) *

Your Age *

Tobacco and Electronic Cigarette Sales: Do The Right ThingPrevention Education Program for Retailers