Epa pledge sign up sheet

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Epa pledge sign up sheet

  1. 1. Take the Smoke-Free Pledge! I pledge to protect myself and others from the health risks of secondhand smoke by keeping my home smoke-free. Before Do you If you live in now, was have Type of Housing an apartment, smoking children (i.e. single family Would you like a kit mailed to you? does yourallowed in under 18 NAME (please print) ZIP CODE home, apartment, Please include your address below condo, townhouse, building haveyour home? in your (Optional) mobile home) a smoke-free home? policy? Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Please return to: The Smoke-Free Housing Coalition 389 Congress St. Room 307 Portland, ME 04101
  2. 2. Before Do you If you live in now, was have Type of Housing an apartment, smoking children (i.e. single family Would you like a kit mailed to you? does yourallowed in under 18 NAME (please print) ZIP CODE home, apartment, Please include your address below condo, townhouse, building haveyour home? in your (Optional) mobile home) a smoke-free home? policy? Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No

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