Adopt-A-Road Program Application

Adopt-A-Road Program Application

Keep Polk County Beautiful, Inc. and the Polk County Board of County Commissioners will work with the adopting group/individual to determine the specific section of County road available. Roadways with lack of sufficiently wide right-of-way will not be considered.
Name of interested Organization, Business, Group or Individual :
President, Chairperson, Etc.:

First NameLast Name
Contact Name:*

First NameLast Name
Contact Mailing Address:*

Street Address

Street Address Line 2

CityFlorida

Postal / Zip Code
E-mail:*
Home Number:

Area CodePhone Number
Cellular Number:*

Area CodePhone Number
Work Number:

Area CodePhone Number
Organization/ Business Website:
Anticipated number of members participating in the program:
Road section(s) you are interested in adopting
Please list the City in which the interested roadway is in and the length of which you wish to adopt. You may list multiple roads.
Signature

Clear
Signature date
Should be Empty: