Keep Polk County Beautiful



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Keep Polk County Beautiful and the Polk County Board of County Commissioners will work with the adopting group to determine the specific section of County road available. Roadways with a lack of sufficiently wide right-of-way will not be considered.

(Please print or type)

Name of Organization, Business or interested group: _____________________________________ Date: ______________

Mailing Address: ___________________________________________________

City, Zip Code: _____________________________________________________

President, Chairperson, etc: ___________________________________________

Name of Contact Person: _____________________________________________ Day Phone No.: ___________________

Mailing Address: ___________________________________________________ Evening Phone: ___________________

City, Zip Code: ____________________________________________________

In an effort to be a more “green” organization, we are hoping to move towards electronic versions of these forms. Please submit your e-mail address for future correspondence and updates. Of course, we understand if you do not have access to e-mail programs, and will be happy to continue our correspondence via phone and mail.

E-Mail Address: ___________________________________________________

Anticipated number of members participating in the program: _______________

Street section(s) you are interested in adopting: Assigned

1. ___________________________________________________ (

2. ___________________________________________________ (

3. ___________________________________________________ (

4. _________________________________________________________ (

Mail this form to: Keep Polk County Beautiful, Inc.

P.O. Box 123

Eagle Lake, FL 33839

Phone: (863) 875-8911

kpcbeautiful@

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Application Form Adopt-A-Road Program

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