Illinois Tobacco Quitline: REQUEST A CALL FROM THE QUITLINE

REQUEST A CALL FROM THE QUITLINE

Printable Enrollment Forms

To request a call please complete the form below. Required fields are in BOLD.

First Name	Last Name
Address
City	State: ZIP:
Phone
Email Address
Gender	Female Male
Ethnicity
Birth Date	//
Would you like to receive a call from the Quitline? Yes No
If yes, when should we call?:	(CST)
Would you like to receive an email response to your tobacco quit line questions? Yes No
Would you like to receive printed materials related to your question? Yes No
Is there a specific problem you would like to discuss? If so, describe below:

How did you hear about the Tobacco Quitline?