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Smoke Free Database Registration Form
Please fill in this form to become a member of Smoke Free Hampshire and Isle of Wight.
Your details will be held on our Database and will be used to send you details of alliance activities and to keep you up-to-date with the work of Smoke Free Hampshire and Isle of Wight. If you have any enquires please email
enquiries@smokefreehampshire.co.uk
About You:
Title:
Please Select ...
Mr
Ms
Miss
Mrs
Dr
Other
Other:
Name:
Job title:
Organisation:
Address:
Post Code:
Telephone Number:
Mobile Number:
Fax Number:
Email:
Website:
Please identify which Primary Care Trust area(s) you cover:
Hampshire (Northern Area)
Hampshire (Western Area)
Hampshire (Eastern Area)
Southampton City
Portsmouth
Isle of Wight
All PCTs
Please identify which Local Authority area(s) you cover:
Rushmoor BC
Hart DC
Basingstoke and Deane BC
East Hants DC
Winchester CC
Eastleigh BC
Test Valley BC
Southampton CC
New Forest DC
Isle of Wight
Portsmouth CC
Fareham BC
Gosport BC
Havant BC
Hampshire CC
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