schedule

 
Home > Join Us > Application
If you are joining TCLN, please fill out this online membership application. If you would prefer to print out the form, you can mail or fax your completed application to: Oregon Health & Science University, Smoking Cessation Center, 3181 SW Sam Jackson Park Rd, CR115, Portland, OR 97239. Fax: 503-494-5407
Contact Information
* - required fields
 
*First Name:
  Middle Initial:
*Last Name:
*Degrees:
*Organization:
*Position/Title:
*Address 1:
  Address 2:
  Delivery Address 1:
  Delivery Address 2:

*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
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
Training of Health Professionals


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.