Tell Us Your Story!

Everyone Has a Story
Do you have a story that could inspire others to quit smoking? Why not share it? Whether you've already quit - or have been trying to quit for a day, a month, or even a year... we want to hear what you have to say. All you have to do is complete the following form. If your story is selected, you could receive $200 and be invited to appear in our next TV commercial!

Please fill out the form below. *ALL FIELDS ARE REQUIRED.

*City: *State: *Age: *Sex:
*Phone Number:
*Primary language spoken:English/Spanish or Other
*Are you aware of the Smoke Free Set Your Date media campaign?
Yes No: If so, did it influence your quit?
*What is the most effective way you receive your media:
TV, Radio, Online or Outdoor
*What types of shows do you watch?
*What radio stations do you listen to?
*What is the most frequent website you go to? Facebook, Twitter, MySpace or Other
*Have you already quit smoking?

If not, when do you plan to quit?

Your Story: Please summarize your Quit Story and why you want to participate in
Smoke Free Set Your Date Series.

*What makes your situation unique? What are your goals?

Referred By (Name):

Referral's Email Address:

Referral's Phone Number:

Please read Application Release Agreement
*PLEASE CHECK By checking this you have read and agree
to the Application Release Agreement.