Join Us
* First Name:
Middle Init:
* Last Name:
* Degrees:
* Organization:
* Position:
* Address1:
Address2:
* Delivery Address1:
Delivery Address2:
* City:
* State:
* Zip Code:
* Office Phone:
Extension:
Fax:
*Office Email:
*Interest Areas: (check more than one if applicable):
	Developing and Implementing Comprehensive Approaches Reaching Employers and Purchasers Health Care System Initiatives Tools and Resources for Health Professionals How to Quit Resources for Tobacco Users Medicare and Medicaid Initiatives Policy Development Quitline Operations, Research and Development Reaching Special/Priority Populations Training of Health Professionals
*Expertise: (check more than one if applicable):
	Developing and Implementing Comprehensive Approaches Reaching Employers and Purchasers Health Care System Initiatives Tools and Resources for Health Professionals How to Quit Resources for Tobacco Users Medicare and Medicaid Initiatives Policy Development Quitline Operations, Research and Development Reaching Special/Priority Populations Training of Health Professionals
*Please read this participation statements and check if you agree:
I agree to collaborate in the sharing of information and resources, especially regarding implementation of cessation programs and initiatives, whenever possible.
I agree to have my contact information posted on the TCLN membership directory.
* - Required Fields