Customer Information Form (CIF)
National Network of Tobacco Cessation Quitlines
Site Information
General Contact Information:
|Name: | |Phone: | |Email: | |
|Organization: | |Title: | |
|Address: |
|City: | |
|State: | |ZIP: | |
Technical Information:
|On-Site Technical | |Phone: | |Email: | |
|Contact: | | | | | |
|States Covered by your Quitline: | |
|Current toll-free number: | |
|Toll-free termination number: | |
|Name of local phone provider (ie, Verizon, SNET, GTE, etc): | |
|Name of long distance provider (ie, MCI, Sprint, AT&T, etc): | |
|Type of telephone equipment you have (ie, Avaya, Nortel, Siemens, etc): | |
|Notes: |
Please email the completed form to Robert Zablocki at zablocb@mail. or fax to 301-402-2594
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