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2. 

4. I hereby acknowledge receipt of the following items that are to be utilized in the Adopt-A-Street clean-up project. I understand that by signing out the equipment, I assume responsibility in the event that the equipment is lost or damaged. 

   The Department of Public Works requires a minimum of seven business days to prepare equipment and supplies for each event. Requesters will receive notification when supplies are ready for pick up at the Department of Public Works. The office is located at 1600 S. Park Road, Hollywood, FL 33021. Offices hours are Monday – Thursday  7:00 a.m. to 6:00 p.m.

   NOTE: ALL CAN CATCHERS MUST BE RETURNED AT THE END OF EACH PROJECT.

6. Date of Event:*
   Date of Event:
8. Location of Event:*
10. Organization Name:*
12. Phone Number:*
14. Mailing Address:*
16. City*
17. State*
18. Zip*
20. E-Mail Address:*
21. Alternate Phone Number:*
23. Supplies:
25. Can catchers:*

    Quantity

26. Trash bags:*

    Quantity

27. Vests:*

    Quantity

28. Gloves:*

    Quantity

30. Special Requests / Comments:
32. Equipment Check Out Date:*
    Equipment Check Out Date:
33. Initial:*
35. Equipment Return Date:*
    Equipment Return Date:
36. Initial:*
38. I Accept*

    1. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.
40. Electronic Signature:*
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field