Contact name *

First Name

Last Name

Contact Phone

(###)

###

####

Date of Cleanup *

MM

DD

YYYY

Will you require safety signs for your cleanup? *

Includes stand and orange "litter pickup ahead" signs. Two available.

Yes, 1 sign

Yes, 2 signs

No

Time to pick up supplies

You may leave this blank if you want to discuss

Hour

Minute

Second

AM PM

Date to pick up supplies

You may leave this blank if you want to discuss

MM

DD

YYYY

How do you plan to dispose of the trash? *

I will be taking the trash to the lanfill and will need a waiver to waive the cost.

I will be disposing of the trash in my personal/company dumpster

I will be requesting city/county pickup

I am unsure

Contact name *

First Name

Last Name

Date of cleanup *

MM

DD

YYYY

Disposal method *

I disposed of the trash in my personal/company dumpster

I disposed of the trash at the landfill

I am requesting city/county trash pickup. Below is the exact location of the trash.

I will send two pictures of my cleanup to director@keepblountbeautiful.org. One of the pictures will be of the picked up trash. *

Check this box to confirm

Option 2

Our cleanup can be shared on social media. *

Yes

No