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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 free handouts or posters about the MyLastDip programs just complete the information in the form, below.

E-mail Address:
Name:
Address:
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State/Province:	Select State/Province 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 Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon   Zip/Post Code:
Organization Name:
Organization Type:	School Tobacco Control Organization Other (please describe:)
E-mail Address:
Phone:	(xxx-xxx-xxxx)
	(1) Program Packet (includes 25 flyers and a cost calculator)
	More than one Program Packet quantity
	(1) 12x17 Poster
	More than one Poster quantity
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