Private Club Exception Reporting Form

Clean Indoor Air Act

INSTRUCTIONS

This form may be used to report the result of the vote of the Private Club(s) officers under the provisions for Act 27 of 2008, the Pennsylvania Clean Indoor Air Act. This report is not mandatory; the Department of Health (DOH) recommends that the status of the vote be reported. The information provided will allow the DOH to provide assistance with compliance.

This form can be completed electronically by tabbing from field to field and entering the required information. Once you have completed the form you can click the ‘Submit’ button.

If you are uncertain about how or where to submit the report, or would like more information, call the Division of Tobacco Prevention and Control at (717) 783-6600. Click here to learn more.



Section:I
Type of Club:	Volunteer Ambulance Volunteer Fire Volunteer Rescue Other * (For definitions click on the link)
Club Name:	*
Identification Type:	EIN (Employer Identification Number) SSN (Social Security Number)
EIN:	* '999999999'
Date Club Established:	*
Club Address:	*
City:	*
State:	Zip Code: - *
County:	*
Contact Person:	*
Phone:	()- *

Section:II
Club Status:	Our Club is smoke free at all times.
	On a vote was taken and recorded by the officers of our private club to address smoking. *

	Clean Indoor Air Act

The Clean Indoor Air Application is currently undergoing maintenance.