Just Be Smokefree Application Form

I am a non-smoker. an occasional smoker. a daily smoker.

I promise to Just Be Smokefree from 1st October 2005.

Name:

Address:

Postcode:

Home telephone number, including area code:

Gender:  Age: Male Female

Teacher/Tutor name:

How often do you smoke?

How many do you smoke...

A day: A week:

Do you want support now or in the future?

What kind of support do you feel you need? Teacher Literature Other (please specify):

Have you thought of stopping before?

Have you ever tried to stop before?