Clean Indoor Air Act
Private Club Exception Reporting Form

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:

*
(For definitions click on the link)
Club Name: *
Identification Type:
EIN: * '999999999'
Date Club Established: *
Club Address: *
City: *
State:    Zip Code: - *
County: *
Contact Person: *
Phone: ()- *
Section:II
Club Status:
On a vote was taken and recorded by the officers of our private club to address smoking. *