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Road Cleanup Request Form

2. Orange County Litter Control Road Cleanup Request Form
   Use this form to submit information about a road in need of cleanup. Information from this form will help identify problem areas and allocate resources. However, submission of this form does not guarantee a cleanup; it is dependent on the availability of groups and resources. Roads must be physically located in Orange County, Virginia.
4. Requestor Contact Information
   In this section, please provide contact information for yourself. Requests should be submitted by Orange County, Virginia residents. We may need to contact you for more information regarding your request.
6. First Name*
7. Last Name*
9. Group/Organization (If Applicable)
11. Address*
13. City*
14. State*
15. Zip*
17. Phone Number*
18. Email Address*
22. Location Information
    In this section, please describe the portion of road for which you're requesting a cleanup. You MUST be specific about start and end points; simply putting a route number will not work. Requests should not be made for sections longer than 3 miles.
24. Main Route Number or Road Name*
    Provide the route number or road name for the stretch of road. It must be within Orange County, Virginia.
25. Start Point*
    Enter a recognizable start point. PREFERABLY, THIS WILL BE AN INTERSECTION, but it can also be an address, business, or landmark.
26. End Point*
    Enter a recognizable end point. PREFERABLY THIS WILL BE AN INTERSECTION, but it can also be an address, business, or landmark.
28. VDOT Adopted*

    Is this road currently adopted in the VDOT Adopt-A-Highway Program?

    1. Yes
    2. No
    3. I Don't Know
29. VDOT Adopted, Part 2

    If you answered "Yes" to the first VDOT Adopted question, are you/your organization the current adopter?

    1. Yes
    2. No
30. Cleanup Help*

    Regardless of adoption status, would you/your organization be willing to assist with a cleanup effort?

    1. Yes
    2. No
32. Additional Information
    Use this field to provide additional information that may help arrange a cleanup or ensure a safer cleanup.
33. Agreement*

    I certify that I/my organization primarily reside in Orange County, Virginia. I have provided truthful information to the best of my ability. I understand that submission of this form does not guarantee a cleanup. I understand that cleanups are dependent on available groups, resources, and weather.

    1. I agree to the above.
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field