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Please contact us by completing this form and pressing the “Submit” button, below. Rest assured that your contact information will be used only for research project purposes.

If you would like to receive handouts & posters about the MyLastDip programs, or request a guided tour of the youth program, just check the boxes at the bottom of this form.

Name:
Address:
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City:
State:	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Mariana Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington Washington, DC West Virginia Wisconsin Wyoming   Zip: (xxxxx)
Organization Name:
Organization Type:	School Tobacco Control Organization Other (please describe:)
E-mail Address:
Phone:	(xxx-xxx-xxxx)
Adult Program Handouts: (1packet includes 25 circle cards, 25 flyers, and a cost calculator)
	1 Packet
	More than 1 Packet (please describe below)
Poster:
	1 Poster
	More than 1 Poster (please describe below)
Youth Program Handouts: (1packet includes 25 circle cards, 25 flyers, and a cost calculator)
	1 Packet
	More than 1 Packet (please describe below)
Poster:
	1 Poster
	More than 1 Poster (please describe below)
Guided Tour:
	Contact me with details
Please tell us how many handouts or posters you would like to receive or send us your questions or comments:
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