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2. We Want to Make Montgomery County More Beautiful!

   (Please use this form if you are planning your own cleanup event.)

4. Contact Name*
6. Group / Organization Name (If Applicable)
8. Address*
10. City*
11. State*
12. Zip Code*
14. E-mail (correspondence will be transmitted by e-mail if listed)
16. Contact Phone Number*
17. Fax
19. Brief Description of Cleanup Project (include date/time, special activities, beautification, etc.)

23. Number of Volunteers

25. Adults
26. Children (14 and under)

30. Quantity of Materials

    Please estimate the number of materials you can use. Quantities may be limited.

32. Glad Trash Bags (30 gallon)
33. Disposable Gloves
34. Certificate(s)

38. Once you receive confirmation of your registration, your supplies will be ready for pick-up upon appointment, at 2550 Sandridge Dr., Moraine, OH 45439.

40. How did you hear about the Great American Cleanup?
    -- Select One --WebsiteTelevision AdvertisementNewspaperCommunity CalendarLibraryFlyer/BrochureOther
42. If "other" please describe:
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field