QUIT AND WIN APPLICATION FORM

I HAVE STOPPED TODAY    _________________________

Name: __________________________________________________________

Address: ________________________________________________________

________________________________________________________________

_______________________________________ Postcode:  _______________

Telephone Number (Home):  ________________________________________

Male [   ]   Female [   ]    Age: _______

School / College etc:  ______________________________________________

Teacher / Tutor name: _____________________________________________

How often do you smoke?  _________________________________________

How many do you smoke a day ________________ a week  ______________

Do you want support now or later?                        Yes [   ]      No [   ]

What kind of support do you feel you need?

Teacher:  Yes [   ]      No [   ]                                       Literature:    Yes [   ]      No [   ]

Other (please specify)  _____________________________________________

Have you thought of stopping before?                    Yes [   ]      No [   ]

Have you ever tried to stop before?                         Yes [   ]      No [   ]

Signature: _{______________________________________________________________________}