Peia Tobacco Affidavit PDF Details

In our daily lives, choices and commitments often come with the need to affirm our decisions, especially when they pertain to health and lifestyle changes. The Peia Tobacco Affidavit form serves as a pivotal document for individuals deciding to steer their life towards a healthier path, particularly in relation to tobacco use. This form facilitates individuals in either affirming their tobacco-free status or acknowledging their current tobacco use while committing to a cessation program—or, in some cases, not committing to any program at all. It requires the individual to provide a full name, make a clear declaration about their tobacco use status by checking the appropriate box, and understand the implications of their choices, including the commitment to notify relevant parties if their tobacco use status changes within a year. Moreover, the affidavit underscores the severe repercussions of providing false information, highlighting fraud and potential disciplinary actions. It caters not just to employees but also extends to spouses or domestic partners, ensuring a comprehensive approach to promoting a tobacco-free environment. This document emphasizes honesty, commitment, and the importance of making informed health choices, underpinned by a legal acknowledgment of the individual's current tobacco use status and their future intentions.

QuestionAnswer
Form NameTobacco Affidavit
Form Length1 pages
Fillable?Yes
Fillable fields15
Avg. time to fill out3 min 19 sec
Other namesPEIA, wv peia tobacco form, peia tobaco affidavit, wv peia tobacco affidavit

Form Preview Example

Tobacco-Free Affidavit

I, __________________________________________ (print full name), certify that (please check one)

I attest that I am tobacco-free and have not used any tobacco product in the last 6 months preceding signing this affdavit. I also commit to being tobacco-free for the next 12 months. Tobacco-free means I have not used cigarettes, pipes, cigars, chewing tobacco, snuff, or any other type of smoking or smokeless tobacco. I understand that one usage of any tobacco product is considered tobacco use.

I am currently a tobacco user, or I have used tobacco products in the last 6 months preceding signing this affdavit, and I commit to enrolling and completing a Tobacco Cessation program.

I am a current tobacco user and I am not willing to commit to enrolling in a Tobacco Cessation program at this time.

I understand the nature and content of this document, I am of legal age, and I am fully competent to truthfully execute this affidavit.

I certify that, if this information changes in the next 12 months, I will notify _______________. I also

understand that providing false information is considered fraud and will result in disciplinary action.

Choose One: Employee

Spouse

Domestic Partner

If spouse or domestic partner, please list employee’s name: ______________________________

Last 4 digits of SS#: ___________ Gender: Male

Female

Employee ID (optional): _____________________________________ Date of Birth: _____________

E-mail Address: _____________________________________________________________________

Signature: _______________________________________________________Date: _____________

How to Edit Tobacco Affidavit Online for Free

The PDF editor was designed to be so simple as it can be. As soon as you follow the following steps, the procedure for preparing the wv peia smoking affidavit document will be effortless.

Step 1: Click the "Get Form Now" button to get started on.

Step 2: You'll find all of the options that you may use on the document after you've accessed the wv peia smoking affidavit editing page.

These particular areas will create the PDF file that you will be filling out:

portion of blanks in PEIA

Put the demanded data in the truthfully execute this affidavit, I certify that if this information, understand that providing false, Choose One, Employee, Spouse, Domestic Partner, If spouse or domestic partner, Last digits of SS Gender Male, Employee ID optional Date of, Female, Email Address, and Signature Date area.

PEIA truthfully execute this affidavit, I certify that if this information, understand that providing false, Choose One, Employee, Spouse, Domestic Partner, If spouse or domestic partner, Last  digits of SS  Gender Male, Employee ID optional  Date of, Female, Email Address, and Signature Date blanks to complete

Step 3: Hit the "Done" button. Now it's easy to upload the PDF file to your device. Besides, you can easily send it through electronic mail.

Step 4: Prepare at least several copies of the form to keep away from all of the future troubles.

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