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Peoria County Highway Department Adopt-A-Highway Permit Application
This form has been modified since it was saved. Please review all fields before submitting.
Steps
1.
Step 1
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2.
Step 2
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Step 1
Applicant Information
First Name of Applicant
*
This is the first name of the person applying for the permit.
Last Name of Applicant
*
This is the last name of the person applying for the permit.
Applicant Address1
*
Applicant City
*
Applicant State
*
Applicant Zip
*
Applicant Phone Number
*
Applicant Fax Number
Applicant Email Address
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Step 2
Group Information
Name of Organization
*
President / Chairman Name
*
Address
City
State
Zip Code
Phone Number
Fax Number
Email Address
Route Information
First Choice of Road
*
Enter the first choice of road your group wants to adopt.
Second Choice of Road
Enter the second choice of road your group wants to adopt.
The Group acknowledges the conditions of the work, agrees to the terms and conditions set by the County and the Illinois Adopt-A-Highway Act, and agrees to hold the County of Peoria and the County's agents or employees harmless from any and all claims or actions resulting from the Adopt-A-Highway Program.
Electronic Signature of Group Representative (Must be at least 21 Years of Age)
*
By checking "I Agree", you agree and acknowledge your electronic signature is valid and binding in the same force and effect as a handwritten signature.
I Agree
Approved By:
Authorized Peoria County Signature Only
Date Approved
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