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Application to Adopt-A-Highway Sponsoring Organization: Street and/or Box No.: City: Zip Code: Contact Person: E-mail Address: Telephone No.: ( ) The proposed area to be adopted is on Highway ___________, from Milepost ____________ to ____________, both sides. The minimum miles to be adopted is two, the maximum miles to be adopted is six. Only one area will be granted to an organization. Approval is hereby requested to enter within the State highway right-of-way to perform litter removal. Agreement The sponsor agrees that, if granted, a permit to do said work, the following stipulations shall govern: • This application shall have been approved prior to sponsor beginning any operations as requested herein. • The organization shall not be a business, commercial venture, political action committee, or a political organization. • Sponsor agrees to indemnify and hold harmless the State of Nebraska, Department of Roads, 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 allowed to 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. 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 Roads. In consideration of the above, the sponsor and the Department of Roads further agree to the following terms and conditions of this agreement. Sponsor’s Additional Responsibility To perform the work specified in a satisfactory, safe, and professional manner. To conduct a minimum of two safety meetings per year with volunteers or employees who may be expected to carry out this agreement. To provide adult supervision at the work site when volunteers or employees are 15 years of age or younger. To obtain required supplies and materials as may be needed from the Department to carry out this agreement during regular business hours. • The sponsor agrees to give the Department of Roads 48 hours notice of intention to start operations. Notification shall be given to the local Department of Roads’ office at __________________________________________________, phone (_____) _____________. Trash bags will be placed at a predetermined location for pickup by the Department. All unused materials and supplies furnished by the Department shall be returned to the Department. • 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 Roads when litter removal is completed. Erect a sign at each end of the adopted section displaying the sponsor’s name or acronym. A maximum of two signs will be erected. Provide reflective vests, trash bags, and safety literature to sponsor. • The sponsor acknowledges that all personnel involved in this project are initiators and volunteers directed by the sponsor and Department’s Responsibilities Remove trash bags used for litter pickup by sponsor. Assist in removal of litter under unusual circumstances such as when large or heavy or hazardous items are found. 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 Roads’ Approval Recommended for Approval: (District Engineer/Designee) Date: Approved: (Adopt-a-Highway Program Manager) Date: DR Form 57, Apr 05