NTCSC Membership Form

Please complete this form to submit your membership request for the Nevada Tobacco Control and Smoke-free Coalition (NTCSC). You will be notified once the NTCSC Board of Directors has approved your membership. Please note, starred (*) items are required and applications that do not answer all required questions will not be considered. Thank you!

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* 1. Are you joining as:

An Individual

Affiliated with an Organization

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* 2. Your contact information:

Name

Credentials

Organization/Institution

Job Title/Position

Mailing Address

City/State/Zip

Phone

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* 3. How did you hear about NTCSC?

My organization/institution

Web search

Social media

Nevada Cancer Coalition

Referral

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* 4. All NTCSC members are eligible to participate in one or more committees, which generally meet monthly via Zoom. Please indicate if you are interested in receiving more information on any of the following committees.

Policy Committee

Communications Committee

Northern NV Action Committee (focus on tobacco related efforts, including smoke-free workplaces in Reno, Sparks and Washoe County)

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* 5. Please describe the nature of your work or interest in tobacco control and prevention.

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* 6. What skill sets or attributes do you feel you have to bring to the coalition? For example, marketing, communications, advocacy, funding, subject matter expertise, etc.

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* 7. Nevada Tobacco Control and Smoke-free Coalition (NTCSC) does not accept into membership those individuals who are employed by the tobacco and “vape” industry, defined as tobacco manufacturers, wholesale distributors, retail sellers, or importers of tobacco and nicotine products.

I certify that I am not employed by a company or business in the tobacco or vape industry. I affirm that I support the priorities of the NTCSC. I understand that I will not use my membership in NTCSC as an indication of my competence in any representation to the public, nor will I represent my personal views or opinions to the media or the public as official positions of NTCSC in absence of authorization by the Board of Directors.

I agree

I am not sure

Thank you for submitting your membership form to NTCSC. You will be notified once the NTCSC Board of Directors has approved your membership.