*ARTCC Arkansas Cancer Summit 2018 Award Nominations

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* 1. Please enter YOUR information:

Name:

Email Address:

Phone Number:

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* 2. Are you nominating an individual or organization? (Note: You can take this survey again to nominate additional individuals or organizations).

Individual

Organization

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* 3. Name of the individual or organization:
(Note: Organizations can be local or state government agencies, universities or colleges, corporations, for-profits or nonprofits organizations, etc.)

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* 4. individual or organization phone number:

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* 5. Individual or organization email address:

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* 6. Is the individual or organization a member of the Arkansas Tobacco Control Coalition?

Yes

No

Not sure

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* 7. Is the individual or organization's tobacco control work recent? (within the last 2.5 years)

Yes

No

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* 8. Has the individual or organization contributed to reducing the tobacco burden in their target population?

Yes

No