Tobacco Education/Prevention Supply Request Form

2012-2013 School Year, Fargo, West Fargo and Cass County

This form is to be used by appropriate school personnel or a community group representative to request use of tobacco education and prevention display items for education purposes.

Name of person and name of institution requesting item(s):


Phone #:


E-mail:


Date(s) needed:


Grade level and number of students reached with item(s):


Item(s) requested: