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Tell us a little about yourself

• What is the primary reason you're here today?^* This field is required.
  To quit smoking, vaping, dipping, or chewing tobacco To help my child quit vaping Other
• To Improve My Health

  For My Family

  To Save Money

  A Health Condition

  Appearance, Smell

  I Am Pregnant

  I Do Not Smoke
  
  
• Have you smoked at least 100 cigarettes in your entire life?^* This field is required.
  Yes No
• How often do you smoke?^* This field is required.
  Every Day Some Days Not At All
• What is your age group?^* This field is required.
  Under 18 18-24 25-30 31-44 45-64 65 or over
• What is your gender?^* This field is required.
  Male Female Other

• Zip code^* Zip Code has to have 5 digits

Okay, let's set up your login!

Who Referred You to EX Program?

If you were referred to EX Program by your employer, health insurance provider, or another sponsor, that means they have paid for you to access premium features. Please provide the information below to access those features.

If you were not referred here, simply check the boxes below each field.

EX Program features are only available to U.S. residents, so please double check your zip code entered above.

• Employer or Sponsor^* We don't recognize the employer or sponsor name "". Please try a different spelling. If you were not referred to BecomeAnEX or the EX Program for sponsorship, select "Not referred". Required field. If you were not referred to BecomeAnEX or the EX Program for sponsorship, select "Not referred".
  Not referred
• Health Insurance Provider (Aetna, Blue Cross, etc)^* We don't recognize the health plan "". Please try a different spelling. If you were not referred to BecomeAnEX or the EX Program for sponsorship, select "Not referred". Required field. If you were not referred to BecomeAnEX or the EX Program for sponsorship, select "Not referred".
  Not referred