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2. We Want to Make Montgomery County More Beautiful!

   Tell us about your project and receive cleanup supplies free!

4. Contact Name*
5. Group / Organization Name (If Applicable)
7. Address*
9. City*
10. State*
11. Zip Code*
13. E-mail (correspondence will be transmitted by e-mail)*
14. Contact Phone Number*
16. Fax
18. Brief Description of Cleanup Project (include date / time, special activities, beautification, etc.)

22. Number of Volunteers

24. Adults
25. Children (14 and under)

29. Number of Supplies Needed

31. Number of Bags
32. Number of Gloves

36. Once you receive confirmation of your registration, your supplies will be ready for pick-up Monday through Friday, 7:30 am to 4:30 pm, or upon appointment, at 2550 Sandridge Dr., Moraine, OH 45439.

38. How did you hear about our program?
    -- Select One --WebsiteTelevision AdvertisementNewspaperCommunity CalendarLibraryFlyer/BrochureOther
40. If "other" please describe:
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field