APPLICANT INFORMATION

1

Organization/Business or Applicant Name

 *

Organization/Business or Applicant Name

2

Name of Responsible Person

 *

Name of Responsible Person

3

Mailing Address

 *

Mailing Address

4

City, State, Zip Code

 *

City, State, Zip Code

5

Telephone Number

 *

Telephone Number

6

How would you like to receive follow-up application materials? (i.e., safety agreement, waivers)

 *

How would you like to receive follow-up application materials? (i.e., safety agreement, waivers)

mail

email If other, type text here.

other If other, type text here.

7

What is your glove size? Gloves are unisex latex gloves or equivalent.

 *

What is your glove size? Gloves are unisex latex gloves or equivalent.

LOCATION INFORMATION

8

General Location

General Location

9

Trash Can Number (see map for locations)

 *

Trash Can Number (see map for locations)

1

2

3

4a

4b

5

6

7a

7b

8

9

10a

10b

11a

11b

12

13a

13b

14a

14b

15a

15b

16a

16b

10

Intersection/Nearest Intersection

Intersection/Nearest Intersection

11

Nearest Business

Nearest Business

12

Portion of Right of Way

 *

Roadside

---

WORK INFORMATION

13

To be performed by

 *

To be performed by

Volunteers

Own Forces

Contract Forces

14

Type of Work

 *

Litter Removal

15

Estimated Starting Date (NOTE: Adopt-A-Can Permit expires two (2) years after issue date)

 *

Estimated Starting Date (NOTE: Adopt-A-Can Permit expires two (2) years after issue date)

16

Is there anything else you would like us to know?

Is there anything else you would like us to know?

---

The undersigned agrees that the work will be done in accordance with public rules and regulations and subject to inspection and approval.

17

Authorized Signature

 *

Authorized Signature

18

Title

Title

19

Daytime Phone Number

 *

Daytime Phone Number

20

Emergency Phone Number

 *

Emergency Phone Number

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

Page 1 / 1