Worksite Registration Form:
3 options:
• Complete the form onscreen, then print and fax or mail;
• Print first, then neatly fill in information and mail;
• Send an email with all requested information
- Need stickers? Order Here
Name* | |
Title* | |
Worksite* (Business, Non-profit, etc.) |
|
Address* | |
City/ Town* | |
Phone No * | |
Email* | |
*All Fields Required for registration. |
|
Signature |
(Check all that apply) Changes we have made
Changes we plan to make or are considering
|
Print form and MAIL to: | |
TOMPKINS COUNTY: T-Free Zone Registration Tobacco Free Tompkins/ TCHD 401 Dates Dr. Ithaca, NY 14850 FAX: 607-274-6695 |
CORTLAND COUNTY : T-Free Zone Registration Tobacco Free Cortland Cortland County Health Department Room B25 60 Central Ave. CORTLAND, NY 13045 |
Send Email including all requested information | |
For Tompkins County, CLICK HERE | For Cortland County, CLICK HERE |
Your comments
and feedback are always welcome.