NAATPN PARTNERS

Your Name (required):

Your Title (required):

Your Organization:

Your Organization Address:

Your Phone:

Your Email (required):

Your Web Site:

Type of Organization:
 Education Healthcare  Faith Civic Business Youth

Communities/Population(s) Served.

How often is your organization involved in planning and implementing policy activities?

Does your organization have a written tobacco free grounds policy?  Yes No

Does your organization accept funds or other resources from any tobacco company, any of its subsidiaries, or parent company  Yes No

Would you like NAATPN to add your email to the Network List-serve?

Please identify ways that your organization will help maintain and strengthen the NAATPN’s national tobacco control network?

Please identify activities that your organization will conduct to facilitate learning and information sharing between NAATPN’s national network and partners?

Please list the specific activities that your organization wants to involve NAATPN (for example, mobilizing community to pass local policy)