TOWN OF CAMP VERDE

395 S. MAIN STREET

PO BOX 710

CAMP VERDE, AZ 86322

Application for Permit to use Town of Camp Verde Right-Of-Way

Application is hereby made for a permit to enter in upon and use a portion of the Town Roadway and to participate in the Town of Camp Verde ADOPT-A-ROAD Program

(Please print or type)

Name of Organization__________________________________________________________________

If Student Organization, Name of Faculty Advisor____________________________________________

Address of Organization________________________________________________________________

City_____________________________________State_______________________Zip______________

Name of Applicant_____________________________________________________________________

Mailing Address (if different from above)___________________________________________________

City______________________________________State_______________________Zip_____________

Phone_____________________________

By signing, applicant agrees to pick up trash a minimum of 2 times per year and to all provisions (1-4) on the back of application.

Signature of applicant___________________________________________________________________

Road Name________________________from__________________to_______________   _______(Address)

______________________________________________________________________________                                                                                                                                                           

For Department Use Only

PERMIT AND LICENSE

PERMIT NO. ___________________

A permit and license is hereby issued to the foregoing licensee for the purpose containing in the application and upon the expressed condition that every agreement and any special provisions contained herein is faithfully performed.  Work is authorized only for the period indicated below.

TOWN OF CAMP VERDE

Dated: __________________________________

By: _____________________________________

Title_____________________________________

Phone:___________________________________