Exit this survey Question Title * 1. First name Question Title * 2. Last name Question Title * 3. Company Question Title * 4. Mailing address*No P.O. Boxes permitted. Question Title * 5. City Question Title * 6. State Question Title * 7. Zip code Question Title * 8. County Indiana Counties Select the county Adams Allen Bartholomew Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawford Daviess Dearborn Decatur DeKalb Delaware Dubois Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko LaGrange Lake LaPorte Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush Scott Shelby Spencer St. Joseph Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley Out of State Select the county Indiana Counties menu Question Title * 9. Email address Question Title * 10. Phone numberPlease enter the 10 digit phone number with area code first. Do not include paratheses or dashes. Question Title * 11. SMOKE-FREE WINDOW CLING: No Smoking in this Facility (Limit 10) Quantity: Question Title * 12. SMOKE-FREE WINDOW CLING: No Smoking Within 8 Feet (Limit 10) Quantity: Question Title * 13. Poster: 1-800-Quit-Now (Limit 10) Quantity: Next