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San Juan County Health Department
735 S 200 W Suite 2, Blanding, UT 84511
Phone: (435) 587-3838
sanjuanpublichealth.org
Tobacco Fine for Sale to a Minor
Business Information
Organization Name:
Address:
Address:
City:
State/Province:
ZIP/Postal Code:
Phone:
Email:
Date
Owner Name
Contact Phone Number
Contact person if different than owner
Fine Amount:
$500.00
Item Subtotal:
$500.00
Total:
$500.00
Payment Information:
Processing Fee Rates:
Cards:
2.5% ($1.50 min)
(1.5% surcharge for foreign cards)
eCheck:
$0.75
Method of Payment:
Credit/Debit Card
eCheck
Update Name from Above
Name on Account:
Routing Number:
Account Number:
Institution:
Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:
Change Payment Method
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