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I, ______________________________________________ (please print)
do solemnly swear that I have not smoked tobacco in the past year.
Signature ___________________________Age ______ Date _________
This statement was signed in the presence of
_______________________________ (please print)
who is a responsible adult who cares about my health and me.
Adult Signature ____________________________________________
This statement is redeemable for price reductions and giveaways at
participating merchants and is redeemable for an ID tag from
Prevention Video Corporation (see section 2 of the Rewards Program).
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