Healthcare Providers for a Smoke-free Minot 1. Question Title * 1. I would like to join Healthcare Providers for a Smoke-free Minot to show support for smoke-free,indoor,public places. Yes No Question Title * 2. What is your healthcare profession? (cardiologist, pediatrician, chiropractor,respiratory therapist, ER nurse, dentist, etc.) Question Title * 3. Do you give STAMP Tobacco Prevention Coalition permission to include your name in publications as a supporter of smoke-free, public, indoor air? Yes No Question Title * 4. In addition to being listed as a supporter, I would also be willing to do the following activities to move policy forward in protecting the public from secondhand smoke. (Check all that apply) Write a letter to the editor Appear in print ads as a spokesperson Contact state and local leaders Contact other healthcare providers to join Healthcare Providers for a Smoke-free Minot Contribute financially to a Smoke-free campaign in Minot Question Title * 5. Contact Information Name: * Address: City State Zip Code E-mail Address Email Address Home Phone Work Phone Cell Phone Question Title * 6. What is your preferred method of receiving information? (Check all that apply) Mail Office phone Home phone Cell phone E-mail Done