Please confirm that your name and address information is EXACTLY as it appears on your Driver's License or other
government issued identification.
*City, State, Zip:
Thank you for trying to register.
Unfortunately, we were not able to verify your information at this time.
Please print out this registration form.
You can then get your password at the Member log on area using your Personal ID shown at the top of this page.
Because R.J. Reynolds Tobacco Company wants to ensure that we only allow tobacco consumers who
are 21 years of age or older to register to be a member, we must verify your age.
We require a legible copy of a valid, GOVERNMENT-ISSUED ID as a proof of age. Your ID must include:
Date of Birth Address Full Name Signature Last 4 digits of your Social Security Number
If any of this information appears on the back, please copy both sides.
If the information on your ID is not the same as your current name and/or address, please tell us why.
Change in marital status Legal name change Address change/correction
Use P.O.Box Dual residence Misspelling
ATTN DEPT 3WE
PO Box 834011
Richardson, TX 75083-4011
AGAIN, PLEASE ATTACH THESE MATERIALS TO A COPY OF THIS PAGE and mail them
to the address given above. Also, please sign the statement at the bottom of this page.
Or, you may e-mail an electronic image copy of your official ID to firstname.lastname@example.org. In your
email PLEASE PROVIDE YOUR NAME, ADDRESS AND PERSONAL ID number (listed at the top of this email).
Preferred electronic image formats are: .JPG, .GIF, and .BMP.
* Required fields - The last 4 digits of your Social Security Number and Birth Date are required
for age verification and help us from confusing you with another consumer.
Should you have any questions or concerns, please call toll-free
7 days a week, between the hours of 8 a.m. and 8 p.m. Eastern Time.
*What is your birth date? ____/____/_______(MM/DD/YYYY) *Today's date? ____/____/_______(MM/DD/YYYY) *Last 4 SSN _________
I certify that I am an age 21+ tobacco consumer and want to receive premiums, offers, coupons and information from R.J. Reynolds Tobacco Co., R.J. Reynolds Vapor Co., American Snuff Co., Santa Fe Natural Tobacco Co. and/or their affiliates via mail or electronically. I authorize such companies and their agents to confirm the accuracy of the information I have submitted with third party databases. I understand that providing false information may constitute a violation of law.