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					                                                                                     $$)4,
        Delta III Building                                          Tel.:             418 644-4200
        2875 Laurier Blvd, Suite 400                                                1 800 463-4856
        P.O. Box 1500                                               Fax:              418 646-1313
        Quebec QC G1K 8X9
        E-mail:                                                     adm.collectif@lacapitale.com




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12)      HAS SMOKED CIGARETTES, CIGARILLOS, CIGARS OR A PIPE, OR
         USED CHEWING TOBACCO, MARIJUANA, SMOKING CESSATION
         AIDS OR NICOTINE SUBSTITUTES?        IF YES, FOR HOW LONG?                                         year(s)             year(s)                  year(s)
                                                                                    PRODUCT(S):
                                                              DATE OF LAST USE (year/month):

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