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2. Additional information will be sent to Authorized Representative, including Waiver/Agreement document.

4. Name of Sponsor / Team (as will appear on the Leaderboard)
6. Sponsor Address
8. City
9. State
10. Zip Code
12. Phone Number
13. Email Address
15. Website
19. Authorized Representative (all information will be sent/requested from/mailed to)
21. Name
23. Address
25. City
26. State
27. Zip Code
29. Phone (Home)
30. Phone (Cell)
32. Fax
33. Best Time / Place to Call
35. Email
37. Preferred method of receiving and reporting

    1. Email
    2. Mail
    3. Fax
41. Zip Code for Litter Collection

    Please note: Be as specific about the area as possible - for example: Westbrook Road, from Wellbaum to Crestway in Clay and Randolph Townships.

43. Alternate Area Choice
45. Anticipated Number of Participants (16 Max)
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

* indicates a required field