The Mel’s Mixes Starter Pack

Name

Email Address

Cellphone

Delivery Address (Street Address)

Are you currently a cigarette smoker? Are you currently a cigarette smoker? Yes No

Amount of cigarettes per day?

Nicotine strength of cigarettes?

Do you want to stop smoking nicotine products completely? Do you want to stop smoking nicotine products completely? Yes No

What flavours do you prefer? What flavours do you prefer? Fruity Desserts Minty Caramel Chocolate Coffee Sweets Other

Other (Please specify)