Responsible Tobacco Retailer Campaign--Materials Order Form
Please complete this form to request existing Responsible Tobacco Retailer campaign materials developed by the Center for Tobacco Prevention and Control (CTPC), within the Maryland Department of Health and Mental Hygiene.

Materials may be shipped via USPS or UPS. Special delivery instructions should be noted in the field "Special Delivery Instructions." Materials cannot be shipped to PO Boxes. Please provide the exact shipping address in the fields below.

Please allow 2-4 weeks for delivery.

Contact with any questions.

Name/Title/Role *
(example: John Doe/Project Coordinator)
Your answer
Organization *
(example: Maryland Department of Health and Mental Hygiene)
Your answer
Street Address *
(example: 123 Anywhere St.)
Your answer
City *
(example: Town )
Your answer
State *
(example: MD)
Your answer
Zip Code *
(example: 12345)
Your answer
Special Delivery Instructions
Your answer
Phone Number *
(example: 123-456-7890)
Your answer
E-mail Address *
Your answer
Materials *
Select the product(s) and quantities you would like to order. In addition to the items listed below, CTPC has the following items available for order, while supplies last: Retailer Checklist, Retailer Pledge, and Posters (11x17). To order the above materials, please select 'Other' and enter the materials and quantities in the next question.To view the materials visit:
No thanks
Quick Guides
Window Clings
If "Other" enter the items and quantities here
*Based on availability
Your answer
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