
TOBACCO AND VAPOR SERVER AWARENESS FORM
Upon employment, all employees must initial each section, sign, and date this document before selling any tobacco, vapor,
alternative nicotine, or e-liquid products. This form is to be kept on file at the store, be accessible to any clerk or employee
present, and be available at all times for inspection by any employee of Arkansas Tobacco Control.
As an employee of a permitted outlet, I understand that there are certain things I am prohibited from doing and certain actions
that I cannot allow to occur in the outlet. In accordance with Arkansas law and the rules of Arkansas Tobacco Control, I have
read, initialed and acknowledged the following:
(Please initial below)
I will not sell cigarettes, tobacco products, vapor products, alternative nicotine products or e-liquid products
to anyone 21 years of age or older when I know the products will be provided to a person or persons under the
age of 21.
_______ I understand that cigarettes or “tobacco products” includes any substance that contains tobacco, including
but not limited to, cigarettes, cigars, smokeless tobacco, loose tobacco, hookah tobacco, shisha, and cigarette
papers.
I
will not sell single cigarettes or any number of cigarettes less than a full pack (20 or 25 cigarettes packaged
together constitutes a pack) and I understand it is against the law to do so.
________ I understand that sales to anyone under the age of 21 can result in criminal charges being filed against me. I
understand that as a clerk, if I am found guilty of a violation of A.C.A. § 5-27- 227, I shall be subject to a fine up to
$100 per violation, plus local court costs.
I understand that this store may undergo inspection at any time to assess its compliance with the state law
regarding the sale of cigarettes, tobacco products, vapor products, alternative nicotine products or
e-liquid products to a minor under the age of 21.
I understand it is illegal to reuse or refill tobacco boxes with cigars, little cigars, cigarillos
or any other tobacco product. Any person doing this can be charged with a Class D Felony.
By signing below, I hereby certify that I have read and fully understand the above statements. I agree to always follow state
law and not to sell cigarettes, tobacco, vapor, alternative nicotine, or e-liquid products to minors. I further consent to allowing
any
current or potential employer to contact Arkansas Tobacco Control to determine if I have received any citations for
violations
of Title 5, Chapter 27 of the Arkansas Code.
Employee Signature Date Signed
Printed Name of Employee Date Entered Employment
Signature of Owner, Manager or Supervisor Date Signed
FORM ATC R-4 02/2020) (All blank lines on this form must contain information)
DFA - ARKANSAS TOBACCO CONTROL
101 E. Capitol Ave., Suite 401
Little Rock, AR 72201
Phone: (501) 682-9756
Fax: (501) 682-9760
https://www.atc.arkansas.gov
State of Arkansas
Department of Finance
And Administration