First Name: Last Name: Street Address:
City: State

Zip:
Email Address: Phone: Age:

Gender: Household income: Marital status:
Number of Kids Ages/Gender Education
Occupation    
   
  1. What do you smoke? Cigar Pipe Cigarette

  2. How often do you smoke? Daily Weekly Special Occasion

  3. If you smoke cigarettes, how many packs a day do you smoke? 1/4 ½ 1 1+

  4. What is your preferred brand of cigarettes?

  5. If you are a cigar smoker, where do you shop? online catalog Cigar Shop-Smoke Shop N/A

  6. Do you have a preferred brand of cigars?

  7. Do you own/rent a humidor? own Rent N/A

  8. If you enjoy a libation with your cigar, what is your drink?

  9. How do you characterize yourself as a smoker? casual social heavy

  10. Is your right to smoke important to you? yes no depends

  11. What is the most important factor in choosing what to smoke?

  12. Are you interested in quitting? yes no

Thank you for your time.
The information you provided will help us bring you only targeted offers
that will save you time in your busy schedule.

Unless I have checked any of the boxes below, Take 5 Solutions, LLC will assume that I do not mind receiving online, postal or SMS offers:
  
I would prefer not to receive online offers, product information,
specials, updates from third party advertisers
 
I would prefer not to receive postal offers, product information,
specials, updates from third party advertisers