Please print and sign.  We must also have clear, readable copy of your driver's license in order to ship to you.  You can send a copy of your driver's license via email or through the US mail.  A faxed copy of your driver's license is not acceptable.

 

 

Customer Certification – ORS Chapter 323, Section 75 and Section 76

I certify that I am at least the legal minimum age (currently 18 years of age) to purchase tobacco.

I certify that I live at:

Street Address: ______________________________________________________

______________________________________________________

City: __________________________ State:__________ Zip___________________

I am providing a photocopy of my valid, verifiable ID, specifically my ____________________________________(e.g. Oregon Drivers License, Oregon ID, Passport).

I understand that signing another person's name to the certification is illegal.

I understand that the sale of tobacco to individuals under the legal minimum purchase age is illegal.

I understand that the purchase of tobacco by individuals under the legal minimum purchase age is illegal under ORS 167.401.

 

Printed Name: ___________________________________

Signature: _______________________________________ Date: _______________