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Prefix |
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First
Name* |
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Middle
Initial |
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Last Name* |
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Email* |
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Country* |
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Areas
of Interest*
(check all that apply) |
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Upload Picture to your Profile |
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About Me
(Provide brief biographical sketch or summary of your interests) |
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Title |
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Organization
or School |
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Street Address |
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City |
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State/Province |
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ZIP/Postal Code |
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Work Phone |
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Home Phone |
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Cell Phone |
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Fax number |
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Does your organization work with population groups that are
disproportionately affected or underrepresented? |
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If yes, which groups? (Press and hold CTRL key to select multiple
items.)
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Other
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Do you currently work in tobacco control? |
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If yes, how many years have you worked in tobacco control? |
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Which of the following best represents the organization where you
work? |
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Other
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Is the organization where you work a local, state, national, or
private organization? |
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Other
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Is your college, community, or organization currently involved in
tobacco control? |
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Which one of the following best describes your position? |
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Other
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Do you have training in public health? |
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What is the highest level of education you have achieved? |
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Other
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