Test Shopper Statement Search Submit Search Print this Page Home » Health Information » Smoking & Vaping » Tobacco & Vape Retailers » Test Shopper Statement This web page is intended to capture statements from our Test Shoppers. Please fill out the information below. Name of Test Shopper(Required) First Name Last Name Age(Required) Date of Birth(Required) MM slash DD slash YYYY Office Address(Required)Brockville Office - LGLDHU - 458 Laurier Blvd, Brockville, Ontario K6V 7A3Smiths Falls Office - LGLDHU - 25 Johnston Street, Smiths Falls, Ontario K7A 0A4SFOA Inspector(s) On Duty(Required) Chris Eady Other Name of Other SFOA Inspector(s) On Duty(Required) Date(Required) MM slash DD slash YYYY Time(Required) Hours : Minutes AM/PM AM PM AM/PM Premises Name(Required) Premises Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Item(s) Purchased(Required) Tobacco Purchased Electronic Cigarette Purchased Other Items Purchased Description of Tobacco Purchased(Required) Description of Electronic Cigarette Purchased(Required) Description of Other Items Purchased(Required) Total Price Paid(Required) Payment Type(Required) Cash Debit Visa Other Other Payment Type(Required) Sales Person Description(Required)Age of Test Shopper Requested?(Required) Yes No Government Photo Identification Requested?(Required) Yes No Proof of Age Examined?(Required) Yes No Sale Completed?(Required) Yes No Description of Events(Required)AgreementName of Test Shopper(Required) First Name Last Name Date(Required) MM slash DD slash YYYY Test Shopper Statement of Truth Agreement(Required) I certify that this Test Shopper Statement Form is accurate and complete, to the best of my knowledge. CAPTCHA