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

 
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
  • Provide Smoke-free Outdoor Areas (T-Free Zones)
  • At and around our main entrance
  • At exits, docks and service doors
  • At outdoor picnic areas, break areas, and pedestrian areas
  • Other  
  •  
    Support smokers who want to quit by providing information about quitting
  • Available for employees
  • On display for clients or customers
 
Changes we plan to make or are considering
 
 
Order additional Zone stickers here:
(No charge for stickers. Click Here to view stickers and other products)
  • # Front-stick     # Back-stick     # Large Back-stick
     
     Be sure to complete the name and address fields at the top of this page
     
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.