Complete this form and declaration if you wish to elect to be a transitional specialist vape retailer. Note: Do not submit this form until the day the retail store is open to the public Name (required) Business name (if applicable) Registered address (required) Email address (required) Phone number (required) Retail premise addresses nominated to be approved vaping premises (use one address per line if there are multiple premises) Website addresses nominated to be approved internet sites (use one address per line if there are multiple websites) Are your sales from vaping products from each of your nominated retail premises more than 50% of your total sales from those premises? (required) Yes No Are you a New Zealand resident? (required) Yes No Final declaration (required) I declare that, to the best of my knowledge, the information I have provided is complete and correct. Leave this field blank CAPTCHA This question is to prevent automated spam submissions. Please enter the words or numbers shown in the image. Submit
