* 1. Please enter your contact information.

* 2. In case of inclement weather, please provide an alternate phone number where you can be reached.

* 3. Please register me for: (select two options)

* 4. This year’s Institute will include a Roundtable Discussion session, in which small groups will explore specific tobacco control topics, including why each topic is important, typical challenges faced, and factors that can lead to success.

Which discussion group would you like to join? It could be a topic with which you have experience, or one you about which you are interested in learning more. (Select one)

* 5. What is your experience in this topic?

* 6. What is your second choice for the discussion group? (Select one)

* 7. What is your experience in this topic?

* 8. Are you requesting scholarship assistance?

* 9. If "Yes", please indicate what type of scholarship you are requesting. (Select all that apply)

* 10. Would you like your information included on the contact list that will be distributed to Institute participants?

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