West Virginia University Hospitals
Tobacco Free Affidavit
Plan year 2009
Every plan member participating in the Wellness Benefit savings plan must complete this affidavit. If you have not
used tobacco in the last three months and will continue to not use tobacco in 2009, sign below and complete.
I certify that the above statement is true. Falsification of any information may result in disciplinary
Employee Signature ______________________________________________ Date ____________
Print Name _______________________________________ Date of Birth ____/____/____