Request to Prohibit Smoking on Adjacent Rights-of-Way (Opt-In Request)

2. Please use this form to request non-smoking locations on adjacent public rights-of-way for properties that are places of employment outside of the downtown core.
   *There are no fees associated with this request.

   *There are no fees associated with this request.

4. 1. Requester/Property Owner Information

6. First Name*

7. Last Name*

9. Type of property where smoking is currently prohibited*

11. Street Address*

13. City*

14. State Code*

15. ZIP*

17. Email*

18. Phone*

22. 2. Requested Non-Smoking Location*

    Please attach a map, photograph, or diagram showing the right-of-way area(s) adjacent to the property where you are requesting that people be prohibited from smoking.

26. 3. Impacts to Neighboring Properties*

    Are there designated smoking areas on your property?

    1. Yes
    2. No
28. Attach File

    If no, please attached a map, photograph, or diagram showing the neighboring properties where smoking is unrestricted.

32. 4. Electronic Signature
    I certify that I am the owner or an authorized representative of the above-referenced property. I acknowledge that the City approving my request to prohibit smoking 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 also acknowledge that the City approving my request to prohibit smoking on adjacent rights-of-way does not obligate the City, including the Eugene Police Department, to take any specific action to enforce the approved smoking prohibition.

    I certify that I am the owner or an authorized representative of the above-referenced property. I acknowledge that the City approving my request to prohibit smoking 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 also acknowledge that the City approving my request to prohibit smoking on adjacent rights-of-way does not obligate the City, including the Eugene Police Department, to take any specific action to enforce the approved smoking prohibition.

34. Full Name*

35. Date/Time*
    Date/Time

    Date/Time

Leave This Blank:


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

    This field is not part of the form submission.

38. Submit

* indicates a required field