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Cleanup Program
Please print the following form, complete it, and return it to
Attn.: Cleanup Program
12000 Government Center Parkway, Suite 467
Fairfax, Virginia 22035-0059
Phone: 703/324-5471
Fax: 703/324-3950
Sign-up Sheet
Name of Group_______________________________
Address____________________________________
___________________________________________
Contact Person ______________________________
Telephone Number (Work) ______________________
Telephone Number (Home)_______________________
Email ________________________________________
Area of Cleanup__________________________________
_______________________________________________
Number of Volunteers (Estimate) _____
Date of Cleanup __________________
How many hours will you work? (Estimate)__________
Will you need safety vests? (if working on primary or secondary road) Yes No
If yes, how many? __________
Supplies will be sent to your district government center:
Braddock District ___
Dranesville District ___
Hunter Mill District ___
Lee District ___
Mason District ___
Mt. Vernon District ___
Providence District ___
Springfield District ___
Sully District ___
Government Center ___