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Adopt-A-Spot
Please Print this agreement and submit it to:
Clean Fairfax
Council
Rosemary C. Byrne
Executive Director
12000 Government Center Parkway
Suite 467
Fairfax, Virginia 22035-0059
(703) 324-5471
Fax (703) 324-3950
In order to enhance the environment and the appearance of our community, we, the undersigned. request permission to Adopt-A-Spot at the following location (address or boundary description)
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Said work will be performed under and in accordance with the Clean Fairfax Council, Inc. terms attached hereto and incorporated herein by reference.
Applicants with whom agreements are signed shall at all times indemnify and save harmless the Commonwealth, all Commonwealth employees, agents, and officers, and the local government or jurisdiction, their officials or agents, Clean Fairfax Council, Inc., their Board of Directors, employees or agents from responsibility, damage, or liability arising from the exercise of the privileges granted under this agreement.
This agreement may be terminated by Clean Fairfax Council, Inc. at any time the applicants do not comply with this agreement or at any time the applicant's work effort is considered unsafe. The Council reserves the right to revise or discontinue this program at any time.
NAME(print)___________________________________
SIGNATURE ______________________________________
TITLE ____________________________________________
ADDRESS _______________________________________TELEPHONE _____________________________________
As part of the Adopt-A-Spot program, Clean Fairfax Council will provide one sign which the adopting group or individual must erect or have erected themselves.
EXACT NAME AND SPELLING TO BE ON SIGN:
_____________________________________________
_____________________________________________
_____________________________________________
The undersigned is the owner, agent, or government official or representative who has legal authority to give permission for the property location named in the aforementioned agreement to be involved in and designated in the Adopt-A-Spot program as administered by Clean Fairtax Council, Inc.
__________________
Date
____________________________________________________
Owner, Agent. Government Official or Representative's Signature
_____________________________
Title
Permission is hereby given to perform the work described, insofar as Clean Fairfax Council, Inc. has the right, power, and authority under this agreement:
__________________
Date
___________________________________________
Executive Director, Clean Fairfax Council. Inc