Quit and Win 2009 Form

In order to be eligible for prizes you must:

  • Complete all information on this online form or call us at 795-5990 to sign up before January 14, 2009.
  • Remain quit between January 21, 2009 and February 25, 2009.
  • Record your phone calls with the Maine Tobacco Helpline to be entered into a separate drawing for $200.00.
  • Be present at the Quit & Win celebration in March. Details to come.

Directions: Thank you for your interest in the program. Please complete the following information to participate in Quit & Win. This information will be used to help track and evaluate our efforts.

Background Information

  1. Background Information

  2. (required)
  3. (required)
  5. (required)
  6. (required)
  7. (required)
  8. (required)
  10. (required)
  11. Preferred Communication Method
  12. (required)
Tobacco History

  1. Tobacco History

  2. Age you started smoking regularly
  3. (required)
  4. Type of Tobacco product you use (cigarettes, cigars, pipe, snuff, chaw, etc.)
  5. (required)
  6. (required)
  7. Primary reason for wanting to quit
  8. (required)
  9. Please specify a quit date on or before 01/21/2009
  10. (required)
Helper Information

  1. Helper Information

Program Information

  1. Program Information

  2. Will you call the Maine Tobacco Helpline for support and a chance to win additional prizes?
  3. (required)
  4. How did you hear about Quit and Win
  5. (required)
  6. Please enter your comments and any explanations of "other" answers
 

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