Ready to Quit

Please fill out this form to receive a call from a Quit Coach at the Maine Tobacco Helpline, and to have self-help materials mailed to you.

This request is for:
MyselfSomeone Else

Describe Your Role:
Please make sure you have the permission of the individual whose information is being submitted as the HelpLine does need to speak with that individual directly.

Please specify:

First Name (* Required):

Last Name (* Required):

Address (* Required):

Town (* Required):

State (* Required):

Zip (* Required):

Email (Recommended):

Phone (* Required):

What are the best times for the Maine Tobacco Helpline to call?:
8am - 11am11am - 2pm2pm - 5pmAfter 5pm

Is it ok to leave a message at this number?:

Verify Characters:

The Quit Link

The Quit Link