* 1. Business/Organization Name

* 2. Type of business

* 3. Contact Name

* 4. Position/Title

* 5. Email

* 6. Phone number

* 7. Street Address

* 8. City

* 9. Zipcode

* 10. County

* 11. Does your organization have a wellness program?

* 12. If you answered yes, does the program include any or all of the following?

* 13. Does your company/organization have a comprehensive tobacco cessation program/services

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