Application For Vapour Shop Licence

* Name of Vapour Shop (Store Front Name):

* Preferred Language for Correspondence:

English French

Name of Applicant (authorized representative)

(An applicant must be at least 19 years of age)

* First Name:

* Last Name:

* Applicant Date of Birth:

* Email Address:

* Re-enter Email Address:

* Telephone Number:

* Re-enter Telephone Number:

Fax (if available):

Mailing Address of Vapour Shop

* Canadian Address?

Yes No

* Vapour Shop location different from mailing address?

Yes No

Location of Vapour Shop

* Postal Code:

* Street Number:

* Street Name:

* Street Type:

* City, Town or Village:

* Province:

Organization or Individual to receive Annual Renewal Notice

* Please indicate preferred method to receive Annual Renewal Notice:

Mail Email Address

Types of Vapour Products to be sold or offered for sale (Check all that apply)

* Disposable E-cigarettes or cigalikes

* E-cigarettes with prefilled or refillable cartridges

* E-liquid

* Tanks or mods

* Pod-mods

* Other

* From whom do you purchase vapour products:

Intended dates and times of operation (check all that apply)

Months

* Select all months

Days

Hours of Operation

* Select all days

Opening Closing

Sunday

To

Monday

To

Tuesday

To

Wednesday

To

Thursday

To

Friday

To

Saturday

To

I hereby declare that I will abide fully by the standards and requirements for responsible retail sales established in accordance with the Tobacco and Electronic Cigarette Sales Act and New Brunswick Regulation 94-57.

I hereby declare that I have sufficient training, knowledge and experience to operate the vapour shop in accordance with the Act and the regulations.

I hereby declare that the employees have or will have sufficient training, knowledge and experience to operate the vapour shop in accordance with the Act and the regulations.

TYPING IN YOUR NAME AND ELECTRONICALLY SENDING THIS FORM CONSTITUTES YOUR ELECTRONIC SIGNATURE

I hereby make application for a licence to operate a Vapour Shop in accordance with Section 2.01 under the Tobacco and Electronic Cigarette Sales Act.

* Signature of Applicant

* Date

* Enter the code exactly as it appears: