Free Employee Training Acknowledgement; Legal Rstriction on Tobacco Sales to MInors, DDE-255 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-22559 (Rev. 07/2008)

STATE OF WISCONSIN S.S. 134.66(2m)

EMPLOYEE TRAINING ACKNOWLEDGEMENT LEGAL RESTRICTION ON TOBACCO SALES TO MINORS
Use of form: This is a required form. Personally identifiable information on this form is collect to determine compliance with the statutes and will only be used for that purpose. Instructions: Sign form and retain on premises in personnel file. Employee - Name (print) Driver's License Number

Address

City, State, Zip

Home Telephone

Date of Birth (Day, Month, Year)

Store Name

Store Number (if applicable)

Name - Supervisor

I acknowledge (Choose one): I have successfully completed a responsible beverage server training course at a technical college that conforms to curriculum guidelines specified by the technical college system board or a comparable training course that is approved by the department or the educational approval board. (S.S.125.04) I have received training from my employer on compliance with S.S. 134.66. I further acknowledge: I understand State Statute 134.66, (Restrictions on sale or gift of cigarettes or tobacco products). I understand that state law prohibits selling tobacco products to any person under the age of 18. Failure to comply with these restrictions may result in a citation.

SIGNATURE - Employee

Date Signed

SIGNATURE - Supervisor

Date Signed