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Quit Line Materials Order Form

Note: Incomplete forms will delay your order. Please fill in all requested information.

Name

Organization

Phone Number

Shipping Address

Address Line 2

City

State

Zip

Is this a residence?

No Yes

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

Nicotine Replacement Therapy (NRT) Order Form

Note: Incomplete forms will delay your order. Please fill in all requested information.

Name

Organization

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)

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