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Live in Washington County? Order a FREE Tobacco Quit Kit!
Fill out the form below, submit, and your tobacco quit kit
will be mailed shortly!

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Do you use: *

Cigarettes Chew/Snuff Other (pipe, cigar, bidi, etc.)

How long have you been using tobacco? (Specifiy days/months/years) *

Are you interested in quitting? *

Yes No

Which of the following statements best describes how ready you are to make changes in your use of tobacco products: *

“I don’t have any plans to quit.” “I’d like to quit sometime, but just not yet.” “I’d like to stop, but I am not sure I can.” “I want to stop smoking.” “I’m trying hard to stay stopped.” “I don’t smoke anymore.”

How sure are you about your answer to the previous question? *

Very confident Somewhat confident Not very confident

Do you have a smoke-free home? *

Yes No

Are you interested in making a pledge to choose not to smoke in your home and not to allow others to do so? *

Yes No

Do you have a smoke-free vehicle? *

Yes No

Are you interested in making a pledge to choose not to smoke in your vehicle and not to allow others to do so? *

Yes No

I understand that my information will not be sold or used for any purpose other than to contact me on tobacco-related issues. I attest that I am at least 18 years of age and a Washington County resident. *

Yes, I agree with this statement. No, I do not agree.

Live in Washington County? Order a FREE Tobacco Quit Kit! Fill out the form below, submit, and your tobacco quit kit will be mailed shortly!

Live in Washington County? Order a FREE Tobacco Quit Kit!
Fill out the form below, submit, and your tobacco quit kit
will be mailed shortly!