By submitting this application I agree to the following: Access to records. A Cigar Bar, Drinking Establishment, and Tobacco Shop shall make available all books, accounts, revenues, receipts and other
information to the Department of Health, the Department of Revenue, State licensing agency or county board of health as necessary to enforce the Clean Indoor Air Act.
By submitting this application, you authorize the Pennsylvania Department of Health to access any and all financial or business records filed with the Commonwealth of Pennsylvania or any of its political
subdivisions or any agency, board, or commission of the Commonwealth on behalf of the establishment for which you seek an exception.
Affidavit of Business Owner:
I am aware that the information contained in this application is subject to reporting to and auditing by the Pennsylvania Department of Health, Pennsylvania Department of Revenue, Pennsylvania Liquor Control Board,
the Pennsylvania State Police and/or the Bureau of Liquor Control Enforcement. The undersigned hereby affirms that the foregoing information is true and correct to the best of said person’s knowledge, information and belief; said affirmation being
made subject to the penalties prescribed by 18 Pa.C.S.A §4904 (unsworn falsification to authorities)
Signature of Authorized Representative: ___________________________________________________
Printed Name of Authorized Representative: _________________________________________
Date: ___________________ Title of Authorized Representative: _______________________________
(Space for Notary):
Commonwealth of ______________________ County of ______________________________________
Subscribed and sworn
to before me this _________ day of ________ , 20_____.
Notary Public of the Commonwealth of Pennsylvania
MY COMMISSION EXPIRES _____________. By. ______________________________________________
Please send your completed form to:
Division of Tobacco Prevention and Control
Attention: Clean Indoor Air Act
Pennsylvania Department of Health
Room 1032 Health & Welfare Building
625 Forster Street
Fax: (717) 214-6690