Name of Adopting Organization or Individual (Individuals must be at least 18 years of age):

Signature:____________________________________________________

Title:

Date:

Address:

Daytime Phone: Evening Phone:

Exact name and spelling to be printed on sign (please print):

Number of Signs Requested (Check one): ONE TWO

Said work shall be performed in accordance with the James City County terms attached hereto and incorporated herein by reference. Applicants with whom agreements are signed shall at all times indemnify and hold harmless James City County, its employees, the Commonwealth and its employees, their officials or agents, from responsibility, damage, injury, or liability arising from the exercise of the privileges granted under this agreement.

This agreement may be terminated James City County at any time the applicants do not comply with this agreement or at any time the applicants' work effort is considered unsafe. The County reserves the right to revise or discontinue this program at any time.

The undersigned is the owner, agent, or government official/representative who has the legal authority to hereby give permission for the property location named in the aforesaid agreement to be involved in and designated in the Adopt-A-Spot Program as administered by James City County.

Printed Name & Title:

Signature: ___________________________________________________

Date:

Please fill out, print, sign, and mail this form to:

James City Clean County Commission

Attn: Kathleen Lindsay, Adopt-A-Spot Coordinator

1204 Jolly Pond Road

Williamsburg, VA 23188

Phone: (757) 565-4000