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Home My WebLink About2008 Apr 18 - Tobacco Compliance Check FormyobaccwLro- tpliaw%zCFec•: orma ZQ 7--�000; aemu.- L: ) stablfshment SSurvey Fartfefpant% Name« III ('� Address: 1 4 }� Q �i ofPurchaser Ager1ZI Q 16 M 17 SL dMale:)P:FemalM ((l(. �'iibYi' zilr Cock:: 0a Ltq S Name:ofAdultSupervisorr '► ►^ city Time:ofChedc r am CL pMA Date:ofCheck: !� Type:ofEstablishment:: Cr Chaim CI Independent i= NotKnown. DayofthwWeek: Ci Moir. I=Thes [IWed' M'Murs. UFri- CL Sat ClSurr Style -of Establishment (Checkonly One): ❑. Convenience Store JzGroccry Store- O-Bar ❑ DepartmentStore 12 Li uorstore• CI -Private -Club , Legion, etc. ❑. Gas Station Only CIPharm fl3ruR Store- 12 Restaurant ❑ Gas Mini -Mart- 0 Other(bowling alley, golf club etc ❑ Tbbacconist Section• I Was. Compliance- Check completed?Yes Eta. No 11 I, f Yes please continue on to the next question, if No please slip this section and go to section I How, was tobacco marketed?` W Over. -the -counter: youth asks the .clerk:fortheproduct. Q From avending machinewith a.Iockout device. [I Other Describe — Was the Purchaserasked. forM?` Yes:0 No ❑ Was this an ID -based. check?- Yes ❑ NOEL WasthePurchaser asked his/her age?' Yes ❑. No PI Sex of Clerk: Male E4 . Female 12 Approximateage of clerk: CI Teen. 17 Young Adult .91 Adult CI Olden Adult Type oftobacco asked for Q Cigarettes Brand. ofcigarettes asked. for: M Marlboro ❑ Newport CI Other: CI Chew/Dip ❑ Cigars ❑: Other Brand: Was the. sale made?' Yes EF No 0, "Yes" how much did the product cost:. S Was a receiptgiven?'Yes CI. No ❑- Purchaser made payment using: CtS1. bills. CI $5bill(s) C1 SS bill and SI bills/ or changer Sr© bill(s) [2 $20 bill ❑ char amuun- J.- U the youth. did not enter the. premises or did not attempt to purchase tobacco products please: indicate why: l: Out-. of Business Does not sell tobacco Q; Inaccessibleby yowth Ci pMvateclubipersonal. residence` Q Tem . long.term closure- Q: Unlocatabla Q Wholesale only/cartons. 11 Machinebrokerr 11 In operation, dosed attune ofvisit lQ Unsafe to access U Presence•of polim L% Drive:thru onl Q Tobacco out of stock. E Permit Suspended. ❑: Other 12 "Don't sell! buttobacco seem im storetlias- 't: