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