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Northcentral
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Quit Line Materials Order Form
Note: Incomplete forms will delay your order. Please fill in all requested information.
Name
Organization
Email
Phone Number
Shipping Address
Address Line 2
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Zip
Is this a residence?
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Vaping Posters
Vaping Poster: Save, Piggy Bank, Girl
Vaping Poster: Save, Wallet, Boy
Vaping Poster: Lungs Burning
Vaping Poster: What Would You Gain
Vaping Poster: Still Tobacco
Quitline Flyers
Rebecca
Roosevelt
Amanda
Felicita
Jessica
Quitline Square Cards
Rebecca
Rebecca-Spanish
Amanda
Roosevelt
Felicita
Jessica
Brian
LGBTQ
Ellie-Spanish
Brian’s Artery
Brian’s Artery-Spanish
Pregnancy Flyers
Pregnancy flyer, 11 x 17
Submit Order
Nicotine Replacement Therapy (NRT) Order Form
Note: Incomplete forms will delay your order. Please fill in all requested information.
Name
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Email
Phone Number
Shipping Address
Address Line 2
City
State
Zip
Is this a residence?
No
Yes
Location of class
Date of classes/sessions
# of participants
NRT Description
(order by the case, 1 case=12 boxes)
21 mg Patch (14 patches in each box)
14 mg Patch (14 patches in each box)
7 mg Patch (14 patches in each box
4 mg Lozenge (mini mint flavor- 81 pc per box, 4mg
2 mg Lozenge (mini mint flavor- 81 pc per box, 2mg
4 mg Gum (spearmint flavor- 100 pc per box)
4 mg Gum (white ice mint flavor- 100 pc per box
4 mg Gum (fruit flavor- 100 pc per box)
4 mg Gum (cinnamon rush flavor- 100 pc per box)
2 mg Gum (spearmint flavor- 100 pc per box)
2 mg Gum (white ice mint flavor- 100 pc per box
2 mg Gum (fruit flavor- 100 pc per box)
2 mg Gum (cinnamon flavor-100 pc per box)
Submit Order
YLAP Request Form
YLAP Thank You Cards & YLAP Toolkit
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I’d like:
Thank You Cards
YLAP Toolkit
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