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Name:
Email:
Cell Phone Number:
Best way to contact:
Email
Phone Call
Text
Do you identify as African American or Latino?
Yes
No
Have you smoked at least 100 cigarettes in your lifetime?
Yes
No
Do you currently smoke some or most days?
Yes
No
I am available (check all that apply):
Mornings
During the day
Evenings
Weekends
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