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2. Date*
   Date
4. Primary Contact*

   Full Name

6. Group/Organization Name (If applicable)
8. Contact Email*
10. Location of Cleanup:*

    Must be within the City of Fort Pierce

12. Number of Bags*
14. Bag Size (Gallons)*
    -- Select One --4 -10 Gallons12- 30 Gallons31 - 40 Gallons41+ GallonsNot Sure
16. Number of Hours*
18. Number of Volunteers*
20. Please check if this cleanup was part of one of the following events or programs:*

    1. Adopt-A-Road
    2. Quarterly Community Cleanup
    3. Great American Cleanup
    4. Community Service Hours for School
    5. Not Applicable
22. Do you want your trash bags removed by city staff?*

    1. Yes
    2. No, I will dispose of it
24. Specific address where trash bags were left (Enter "N/A" if you are not requesting for trash bag pickup)*

    It will help us locate your trash bags as quickly as possible. Thank you.

    
    

26. Trash Bag Placement Photo

    If you would like to have your bags picked up, please leave them at the edge of the roadway and upload a photo of where you left them. Please make sure to take a wide-angle shot of where your bags were left, include landmarks such as street signs, buildings and other identifying structures. The wider the view of the background the better.

28. Proof of Cleanup Photo*

    Example: Photo of your cleaning activity or group photo with cleaning supplies.

    
    

30. Upload Photo (Optional)

    Example: Photo of cleaning activity, group photo with cleaning supplies.

    Photos may be used to recognize participants and to promote the city's Keep Fort Pierce Beautiful initiatives on the city's website, social media and other communication platforms.

Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field