Rigs without Cigs
Ongoing program to help drivers and their families break the nicotine habit.
Sign in to Google to save your progress. Learn more
Email *
Last Name *
First Name *
CELL Phone Number *
Street Address *
City *
State *
Zip Code *
Preferred Method of Contact *
Are you currently a semi-truck driver? *
If you are a semi-truck driver, what is your CDL#?
What form of tobacco do you use? *
How are you affiliated with the trucking industry? *
Your Age *
Who is your employer? *
How long have you been using tobacco? *
Is this your first time trying to quit? *
What methods have you used in the past to quit? Check all that apply *
How soon after waking do you smoke your first cigarette? *
Do you find it difficult to refrain from smoking in places where it's not allowed? *
Which cigarette would you hate to give up? *
How many cigarettes do you smoke daily? (Ex: 53 cigarettes.)If you don't know, give us your best guess. *
Do you smoke more frequently in the morning? *
Do you smoke even when in sick  in bed most of the day? *
Do you plan to join our Facebook group for support and information? *
Why do you want to quit using tobacco? *
How can we best help you to  no longer use tobacco? *
How did you learn about the Rigs without Cigs program? Check all that apply *
First and Last Name of Accountability Person *
Phone number for Accountability Person *
Relationship to Accountability Person *
Do you currently have a Primary Care Physician? *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.