Public Reporter Form

Contact Information

First Name

Last Name

Title

Phone Number

Email Address

Mailing Address

Country

Type of Reporter

Please select the category that best describes you or your organization.

Company or Organization Info

Company or Organization Name

Is the company or organization mailing address different from your contact information?

Mailing Address

We will periodically send correspondence to the provided address.

Country

Product Information

Please provide as much product information as you can.

Tobacco Product Name

Is this submission regarding only packaging?

Where did you encounter this product?

Please explain where you encountered this product.

Website Link

Please provide a link to the website if possible.

When did you encounter this product?

Do you have a Universal Product Code to provide for this product?

Is this Universal Product Code from physical packaging?

Universal Product Code

Universal Product Code
Universal Product Code

Product Flavor

Flavor Name

Do you believe that this product has a characterizing flavor other than that of tobacco?

How would you describe that flavor?

How did you come to this conclusion?

Please explain how you came to this conclusion.

Product Photos

Please provide any relevant files, including packaging photos, reviews, and/or studies.

Product Files

Other Comments

What code is in the image?

Enter the characters shown in the image.