2011 Request For Proposal Cover Sheet Template Page 11
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11STATE OF CONNECTICUT, Department of Public Health RFP # 2011-0917; Tobacco Use Cessation Services
APPLICATION FORMS
State of Connecticut
Department of Public Health
Tobacco Use Prevention and Control Program
Tobacco Industry Funding and Partnership Certification
I, ___________________________certify that _____________________ has not
(Agency)
received funding or engaged in partnerships, either formal or informal, with any
Tobacco Company within the last three (3) years.
The above-mentioned agency will not accept funding nor engage in partnerships
with any Tobacco Company during the contract period, should we be awarded
funds from the CT Department of Public Health, Tobacco Use Prevention and
Control Program.
___________________________
________________
Contractor’s Authorized Signature
Date
RFP # 2011-0917 APPLICATION FORMS
Page 11 of 11
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