Quit & Win

Quit & Win Registration

Do your shopping online and help us raise money!

If you have ever wanted to quit smoking now is the best time. Fill out this registration form by May 2, 2010 to join the International Quit & Win. If you stay smoke free for four weeks (urine testing required) you will be eligible for the drawing.

The top prize is $10,000.00!


First Name:
Last Name:
Date of Birth:
Sex:	Male Female
Address:
City:
State:
Zip:
Country:
Phone:
Email address:
Cigarettes per day:
Cigars per day:
Pipes per day:
Prior quit attempts:	Never 1 or 2 3 or more
Years of smoking:
Name of witness:
Address of witness:
City of witness:
State of witness:
Zip of witness:
Country of witness:
Email of witness: