Tobacco Affidavit – Fill Out and Use This PDF

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 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.

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

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

E-mail Address: _____________________________________________________________________

Signature: _______________________________________________________Date: _____________