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American Lung Association in Iowa Resource Request Form
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1.
How did you hear about us?
(Required.)
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2.
Contact Information:
(Required.)
First & Last Name
Job Title
Organization
Mailing Street Address
City
Zip Code
County
Email Address
Phone Number
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3.
I am interested in the following tobacco health education resources and incentive items (check all that apply):
(Required.)
General Adult
Youth (13-17)
Pregnancy
Behavioral/Mental Health
Diabetic
Oral Health
Pets
Spanish
LGBTQ+
Smoke Free Housing
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4.
I would like to:
(Required.)
Receive a sample box of requested resources
Request specific materials and quantities
