ADOPT-A-HIGHWAY APPLICATION PERMIT by qdg19622

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									                       ADOPT-A-HIGHWAY APPLICATION & PERMIT
                                          Polk County Highway Department
                                        P.O. Box 248, Balsam Lake, WI 54810
                                      Phone: (715) 485-8700 Fax: (715) 485-8702


County Road Name

Starting Location
(Indicate street name or fire number of starting
location)



Ending Location
(Indicate street name or fire number of ending location)



Group Name
(Print Exact Name of Group to be Printed on Sign)




Name of Group Leader


Mailing Address


City/State/Zip Code

Area Code & Phone
Number

By signature below, the Group acknowledges the hazardous nature of the work and
agrees to the terms and conditions of this application.


_________________________________________________                                                  _________________
Group Leader                                                                                       Date

------------------------------------------------------For Office Use Only----------------------------------------------------------

Application Approval: Polk County Highway Department approves this PERMIT for
the above named group to participate in the Adopt-A-Highway Program. The
Department reserves the right to modify or cancel this permit at any time.


_________________________________________________                                                   ________________
Polk County Highway Commissioner                                                                    Date

  Permit No.



S:\CTY MAINTENANCE\Adopt-A-Hwy\Procedures\Adopt-A-Hwy ApplicationPermit 4-06-09.doc

								
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