Age Verification Form
Name: ____________________________
Email Address: _____________________
Shipping Address: (must match driver’s license)
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Under penalty of perjury, I do hereby swear that I am of legal age (this website requires that all customers be at least 21 years old) to purchase cigars, cigarettes and other tobacco products.  By completing and submitting this form, I understand that I must comply with the law to be able to order and subsequently receive cigars and other tobacco products.  Please print and sign this form.  Please also attach a copy of your valid drivers license or non-driver ID.  You may either fax this form, or mail it along with your payment (check or money order) to:

Black Bear Smoke Shop
P.O. Box 66
Irving, NY 14081

Customer Signature _________________________________