Smoke-Free Housing Directory Request Form

Name of Property*

Primary contact name*

First Last

Primary contact email*

Address*

Street Address Address Line 2 City State ZIP Code

Property Phone*

Primary contact phone

Please complete if different than property phone

Property Website

Total number of units in complex*

Please enter a number from 0 to 9999.

Number of smoke-free units in complex*

Please enter a number from 0 to 9999.

Total number of buildings in complex*

Please enter a number from 0 to 9999.

Number of smoke-free buildings in complex*

Please enter a number from 0 to 9999.

Type of Property*

Please select all types that apply.

Select area of town*

Please choose one

Please submit your lease addendum*

Max. file size: 2 MB.

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