Cigarette Receptacle Interest Form - FNA
Thank you for your interest in the cigarette receptacle program! Please complete this short form so we can determine the best locations for giving out the receptacles.

Project sponsored by a grant from Keep Philadelphia Beautiful.

Business/Organization Name *
Your answer
Business/Organization Address (must be in FNA boundaries) *
Your answer
Your name and role (business owner, manager, etc.) *
Your answer
Best email address *
Your answer
Briefly the location where you want to place the cigarette receptacle. Ideal locations on poles within the property line or mounted on the exterior wall if there's permission from the building owner. *
Your answer
Briefly describe how you plan to maintain the cigarette receptacle. Who will take care of it and how often? *
Your answer
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