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City of Louisville ADOPT-A-LOUISVILLE STREET APPLICATION FORM ====================================================================== ORGANIZATION INFORMATION: Organization Name: Address: Phone: Contact Person(s): Address: Phone: Approximate Number of Participants: ---------------------------------------------------------------------- ---------------------------------------------------------------------- ADOPTION INFORMATION: STREET Name: Number: LOCATION From: To: Planned Start Date: Miles: Planned Schedule: ---------------------------------------------------------------------- ---------------------------------------------------------------------- APPLICANT STATEMENT: I have read and agree to the policies and procedures for the Louis- ville Adopt-A-Louisville Street Program. I understand that the City of Louisville reserves the right to modify the scope of the adoption if, in the opinion of the City, the adopting organization's size is inconsistent with the section as identified above. Further, I under- stand the hazardous nature of the work which is to be performed and take full responsibility for an injury that could occur while working along the roadway. Applicant's Signature Date: Title ---------------------------------------------------------------------- ---------------------------------------------------------------------- APPROVALS: Public Works Director: Date: Traffic Engineer: Date: Street Superintendent: Date: