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2. Notice
   Do not include any sensitive information on this form or (if applicable) files uploaded to this form. Sensitive information includes, but is not limited to, social security numbers, driver’s license numbers, bank account information, routing numbers, medical information, passport numbers, or passwords.
4. Section of road adopted (e.i. From ______ to ______ )*
6. Group Name*
7. Contact Person for Group (First/Last)*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Contact Email Address*
16. Contact Phone Number*
18. Adopted Road Name*
20. Length (in miles) of Adopted Road Segment
22. Do you regularly clean your section of the road?*

    1. Yes
    2. No
24. Do you wish to continue participating in the Adopt a Road program?*

    1. Yes
    2. No
26. How many times a year is your section of road cleaned?*
28. I need more Adopt a Road trash bags.*

    1. Yes
    2. No
30. I would like to request additional safety vests.*

    1. Yes
    2. No
32. 
34. *If leaving the program you may request to keep one of your signs, if greater than 5 years of service, as a thank you from the Berrien County Road Department.
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field