Freedom From Smoking Facilitator Application Form

I am applying for the following Freedom From Smoking Facilitator Training: *
September Baltimore, MD Training: Tobacco Basics webinar, Sept 18th, 11am-1pm & FFS Certification in-person workshop, Sept 25th, Baltimore, MD October Bethesda, MD Training: Tobacco Basics webinar, Oct 24th, 11am-1pm & FFS Certification in-person workshop, Oct 30th, Bethesda, MD October Asheville, NC Training: Tobacco Basics webinar, Oct 16th, 11am-1pm & FFS Certification in-person workshop, Oct 23rd, Asheville, NC October Raleigh, NC Training: Tobacco Basics webinar, Oct 24th, 11am-1pm & FFS Certification in-person workshop, Oct 30th, Raleigh, NC November Norfolk, VA Training: Tobacco Basics webinar, Nov 20th, 11am-1pm & FFS Certification in-person workshop, Nov 21st, Norfolk, VA
Name * First Last
Organization *
Title or Position *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email *
Phone Number * ### - ### - ####
Best way to reach me is: *
E-mail Phone Third Choice
Do you currently use tobacco in any form? *
Yes No
Have you used tobacco in the past? *
Yes No
If yes, how long ago?
Describe your previous experience in tobacco cessation education *
Describe your previous experience working with/facilitating groups *
In what medical and/or community groups do you plan on implementing the FFS program? *
Describe your plan for participant recruitment *
Will you be implementing the FFS program as part of a worksite wellness program? *
Yes No
If yes, please describe *
Please list any of your professional organizations or affiliations
*
I understand that I can be disapproved at any point in the process for volunteer service and, if disapproved, I will receive written notification
*
I certify that the information that I have provided is true and correct to the best of my knowledge.
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