Tobacco Sales Complaint Form

Tobacco Sales Complaint Form



Reminder you have to be 21 years of age or older to purchase tobacco products, electronic cigarette products or nicotine products! “Please use this form to report illegal sales of tobacco products, electronic cigarette products, and nicotine products whether online, by phone or in-person. Please fill out as much information as possible. If you do not have the information needed you can skip to the next question.”

How did the Sale Occur?

How did the illegal sale occur?
Which best describes you?
Describes you: Other

When did the Sale Occur?

Approximate Sale Date
Approximate Sale Time

Product Purchased

What Product(s) was Purchased?

* Tobacco Product: cigar, cigarettes, chewing tobacco, snus, etc
* E-Cigarette Product: JUUL, e-liquid, cartridge, pod, etc
* Nicotine Product: pure nicotine, dissolvable salts, orbs, pellets, toothpicks, nicotine-laced food and beverage, inhaler (not FDA approved NRT)

Description of product(s) purchased:
(brand name, nicotine concentration level, etc)

Pay for Product

How did the person pay for the product?
Photo of receipt
Other Documentation

Activity Occurring

How did you know this activity was occuring?
Are you willing to speak to a representative at Utah Department of Health or your Local Health Department for more information?

Contact Information

Name (Optional)
Phone Number (Optional)
Phone Number Extension (Optional)
Email (Optional)
If you prefer not to give your Name, Phone, or Email, how may we contact you?

Buyer Description

What is the age of the buyer?
Age of Buyer:
Gender
Description of the underage buyer:
(i.e. approx. height, hair color, other markings, etc)

Retailer Web

Retailer Website
Retailer Social Media
Retailer Social Media Handle

Retailer Information

Retailer Business Name
Description of Sales Clerk:
(i.e. approx, age, sex, height, hair color, other markings, etc or UNKNOWN)
Retailer Phone Number
Retailer Phone Number Extension
Retailer Physical Address
State/Region

Thank you, your complaint has been submitted!

Cannon Health Building, 288 North 1460 West, Salt Lake City, UT 84116 | 1-888-222-2542
 
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