epa pledge sign up sheet
TRANSCRIPT
Before
now, was
smoking
allowed in
your home?
Do you
have
children
under 18
in your
home?
NAME (please print)
ZIP CODE
Type of Housing
(i.e. single family
home, apartment,
condo, townhouse,
mobile home)
If you live in
an apartment,
does your
building have
a smoke-free
policy?
Would you like a kit mailed to you?
Please include your address below
(Optional)
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
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.
Plea
se re
turn
to: T
he S
mok
e-Fr
ee H
ousi
ng C
oalit
ion
389
Con
gres
s St.
Roo
m 3
07 P
ortla
nd, M
E 04
101
Before
now, was
smoking
allowed in
your home?
Do you
have
children
under 18
in your
home?
NAME (please print)
ZIP CODE
Type of Housing
(i.e. single family
home, apartment,
condo, townhouse,
mobile home)
If you live in
an apartment,
does your
building have
a smoke-free
policy?
Would you like a kit mailed to you?
Please include your address below
(Optional)
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o
Yes
/ No
Yes
/ No
Ye
s / N
o