Smoke Free Indy » Online Petition

Online Petition

Please Sign Our Online Petition to Support Smoke Free Workplaces.

For questions about this petition please e-mail us.

Name: (*)
Home Address:
City: (*)
Zip:
Business Phone:
Evening Phone:
Email: (*)
Are you registered to vote at current home address?	Yes No
Do you know who your councillor is?	Yes No
Do you know who your state legislator is?	Yes No
Please click here to find out who your councillor and state legislator are and let us know who they are:
Councillor:
Legislator (House):
Legislator (Senate):
Do you work in a smoke free environment?	Yes No
If you do not work in a smoke free environment please let us know where you work:
Do you live in a smoke free environment?	Yes No
Do you live in a Marion County excluded city, i.e. Beech Grove, Lawrence, Speedway, Southport?	Yes No
If yes, which excluded city?:
Please check all that apply:	Keep me informed I will attend an event I will volunteer at an event I will write a letter I will make a call I want to be actively involved