Form 1C

Quit Agreement

I, ____________________________, am quitting marijuana because (fill in reasons for quitting)

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

As of ________________________________, I intend to stop smoking marijuana and to refrain

from use in the future by (fill in strategies to be used)

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Signatures: ___________________________ _____________________________