Employer Quit Captain Signup Question Title * 1. Name Question Title * 2. Email Question Title * 3. Organization/Business Name Question Title * 4. Address (Please include Street Name, City, Zipcode) *Note: We cannot deliver to a P.O. Box Question Title * 5. County Question Title * 6. Title Question Title * 7. Phone Number Question Title * 8. Approximately how many employees are in your organization? Question Title * 9. Does your organization have a wellness program? Yes No I'm not sure Other (please specify) Question Title * 10. If you answered yes, does the wellness program support tobacco cessation services? Yes No I'm not sure Done