Online Forms

2. Please use this form to request smoking locations on public rights-of-way adjacent to private establishments located inside the downtown core.
   *There are no fees associated with this request.
4. 1. Requester Information
6. First Name*
7. Last Name*
9. Name of Downtown Core Private Establishment*
11. Street Address*
13. City*
14. State Code*
15. ZIP*
17. Email*
18. Phone*
22. 2. Requested Smoking Location*
    Please attach a map, photograph, or diagram showing the right-of-way area(s) adjacent to your private establishment where you are requesting that people be allowed to smoke.
26. 3. Opt-Out Request*

    1. All Day
    2. After 9:00 p.m.
30. 4. Electronic Signature
    I certify that I am an authorized representative of the above-referenced private establishment. I acknowledge that the City approving my request to allow smoking within the downtown core on adjacent rights-of-way does not alleviate my responsibility to comply with all other applicable local and state laws, including Eugene Code 6.225 – 6.240 and Administrative Order No. 21-18-07. I understand that, in addition to the penalties provided in City Code, any violation of the applicable regulations may result in the City revoking the permission granted me to allow smoking within the downtown core adjacent to the above-identified property. I agree to encourage patrons to use any cigarette disposal receptacle near the property provided by the City and I agree to work cooperatively with the City in placing the cigarette disposal receptacle in an optimum location for maximum usage.
32. Full Name*
33. Date/Time*
    Date/Time

    Date/Time
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field