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2. Litter Cleanup Report Form

   Please be aware that is required that you complete a cleanup and submit a Litter Cleanup Report Form as proof, before submitting this form. 

4. Group/Organization Name:*
6. Contact Name:*
8. Mailing Address*
10. Phone Number:*
11. Email Address:*
13. Name of Road to Adopt:*
15. Beginning at:*
16. Ending at:*
18. Name to Appear on Sign:*
20. Type Name Below for Signature:*

    By signing this form, you are agreeing to cleanup a minimum of twelve (12) times a year and will report each cleaning through the required Litter Cleanup Report Form, available on the Adopt-A-Road webpage. 

21. Date:
25. Contact:

    Marsha Commond, Public Works: mcommond@cityoffortpierce.com

Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field