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2. GROUP/ORGANIZATION
4. Group Name*
6. Street Address*
8. City*
9. State*
10. Zip Code*
12. Group Leader Name*
14. Type of Group*

    1. Civic Group
    2. Not for Profit Group
    3. Private Enterprise/Commercial
15. Application Status*

    1. First Application
    2. Renewal Application

    (Check One)

17. Approximate No. of Participants for Litter Pickup*
18. Number of Adult Supervisors*

    (If Participants are between 10 and 18 years old.)

20. Name/Acronym for Sign *

    Name/Acronym requested to be on Adopt-a-Highway Sign.  No logos or slogans will be allowed. Limit of 17 characters per line, limit two lines and leave space between words. 

22. GROUP COORDINATOR
24. Name*
26. Street Address*
28. City *
29. State*
30. Zip Code*
32. Email*
33. Phone Number*
35. FIRST CHOICE: Road Name*

    Section of Highway to be Adopted

36. From:*

    Road Name

37. To:*

    Road Name

39. SECOND CHOICE: Road Name*

    Section of Highway to be Adopted

40. From: *

    Road Name

41. To: *

    Road Name

43. Certification*

    1. I Agree

    By checking this box, I hereby certify that the above information is correct and my Group/Organization agrees to conform to the requirements of the Village of Libertyville Adopt-a-Highway Program.

    Your Adopt-a-Highway application will be sent to the Director of Public Works for final approval.   

    Public Works Streets & Utilities staff will contact you when the application has been approved.    Streets & Utilities Staff can be reached at 847-362-3434.

    
    

47. INTERNAL USE ONLY
49. Signature

    Director of Public Works 

50. Date
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field