UW-CTRI: Enrollment Form for a Stop-Smoking Research Study

Complete This Form to Volunteer for a Quit-Smoking Study

Please read all of these instructions before completing the form.
We need at least one phone number to contact you.
The last five pieces of information help us determine how best to recruit participants for important health research. This information is not shared with anyone else.
It may be a few weeks before you hear from us. Thank you for your patience!

Your full name
A daytime phone number (including the area code)
An evening phone number (including the area code)
A cell phone number (including the area code)
The best times to reach you
Your E-mail Address
How you heard about us
If it was on TV, radio or in the newspaper, please let us know what station or what paper OR if you chose 'Other', specify here.
Your City
Your Zip Code
Indicate Your Preferred Location:	Madison Milwaukee

Thank you for your interest and we look forward to speaking with you!