Application to Adopt A Highway
Sponsoring Organization:
Street and/or Box No.:	City:	Zip Code:
Contact Person:	E-mail Address:	Telephone No.: ( ) -

Proposed area to be adopted: Highway ____________, from Milepost ____________ to ____________, both sides (minimum miles is two, maximum miles is six.) One adopted area per organization. Approval is hereby requested to enter within the State highway rightofway to perform litter removal.

Agreement

The sponsor agrees that if a permit to perform litter removal is granted, the following stipulations shall govern:

This application shall have been approved prior to sponsor performing any litter removal.

The organization shall not be a for profit commercial venture, political action committee, or a political organization.

Sponsor agrees to indemnify and hold harmless the State of Nebraska, Department of Transportation, its officers and employees from all liability, judgment, costs, expenses, claims growing out of damages, or alleged damages of any nature whatsoever to any person, property, or third party arising out of the performance or non-performance of said work.

No vehicles, equipment, or materials are to be parked or stored within 30 feet from the edge of the pavement, except during times of litter pickup when a vehicle may be parked on the shoulder.

Right-of-way markers and land monuments shall not be removed, altered, or damaged.

This permit shall be subject to any laws now in effect, or any laws which may be hereafter enacted, and all applicable rules and regulations of local, state, and federal agencies.

The sponsor agrees to give the Department of Transportation 48 hours notice before performing litter removal. Notification shall be given to the local Department of Transportation’s office at _____________________, ________________________.

Phone (____) ______-________.

The sponsor shall carry on the work as required and authorized by this agreement with serious regard to the safety of the traveling public, adjacent property owners, and volunteers or employees of the sponsor. Traffic protection signs will be loaned to the sponsor for use in traffic control and returned to the Department of Transportation when litter removal is completed.

The sponsor acknowledges that all personnel involved in this project are initiators and volunteers directed by the sponsor and

that the sponsor accepts full responsibility for any injuries or damages sustained by or caused by such personnel. The sponsor acknowledges that it or its volunteers are in no way considered to be employees of the State of Nebraska, Department of Transportation.

In consideration of the above, the sponsor and the Department of Transportation further agree to the following terms and conditions of this agreement.

Sponsor’s Additional Responsibilities

Perform the work specified in a satisfactory, safe, and professional manner.

Conduct a safety meeting with volunteers or employees prior to each litter removal event.

Provide adult supervision at the worksite when volunteers or employees are 15 years of age or younger.

Obtain required supplies and materials from the Department during regular business hours.

Filled trash bags will be placed at a predetermined location for pick up and disposal by the Department.

All unused materials and supplies furnished by the Department shall be returned to the Department.

Department’s Responsibilities

Install a recognition sign at each end of the adopted section displaying the sponsor’s name or acronym. A maximum of two signs will be installed.

Provide reflective vests, trash bags, and safety literature to sponsor.

Remove trash bags used for litter pickup by sponsor.

Assist in removal of litter under unusual circumstances such as large, heavy or hazardous items.

The Department reserves the right to terminate this agreement and remove Adopt-A-Highway signs when, in the sole judgment of the Department, it is found that the sponsor has not met the terms and conditions of the agreement.

This agreement shall remain in force from _________________________ to_________________________. The sponsor agrees to pick up litter two times a year for a period of two years. The present sponsor will be given first option to renew the permit at the end of the agreement period.

Sponsor:	Signed by:

State of Nebraska, Department of Transportation’s Approval

Recommended for Approval: (District Engineer/Designee)	Date:
Approved: (Adopt-a-Highway Program Manager)	Date:

NDOT Form 57, July 17