• Register Your Worksite’s Tobacco Free Zones

    Worksite Registration Form:
    3 options:
      • Complete the form onscreen, then print and 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 eligible registration.
     
      (Check all that apply)
       
      Changes we have made at my worksite
    • T-Free Zone sticker at our main entrance
    • Posted other doorways and/or outdoor areas as T-Free Zones
    • Only magazines with no tobacco ads in our customer waiting area(s)
    • Other  
    •  
      Changes we plan to make or are considering
      (including pledges or policies):
      Refuse donations from tobacco companies
    • Prohibit tobacco company involvement in our annual events
    • No tobacco promotions or cosponsored events
    • Other  
    •  
      For Tobacco Retailers:
      Removed or reduced outdoor tobacco ads
    • Removed tobacco ads from store entrance
    • Removed or reduced indoor tobacco ads
    • Moved tobacco ads at least 5 feet from candy and toy displays
    • Other  
    • Yes, it is OK to list our worksite in T-Free Zone promotions
    •  
       
      Order additional Zone stickers here:
      # Front-stick    # Back-stick    (No charge for stickers)
       
       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
     

    		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.
     

     

     

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    T-Free: Tobacco Free Tompkins is funded by a grant to the Health Promotion Program at the Tompkins County Health Department