Date: ______________________

Applicant’s Name: ____________________________________________ Phone No.: ________________

Name of Organization: ___________________________________________________________________

Address: ______________________________________________________________________________

Applicant’s Signature*: ___________________________________________________________________

*THIS SIGNATURE OF THE APPLICANT SHALL BE DEEMED AS EVIDENCE OF HIS OR HER WILLINGNESS TO ASSUMPTION OF FULL RESPONSIBILITY FOR ANY DAMAGES TO ANY PROPERTY THAT MAY RESULT FROM SIGN PLACEMENT, AND FURTHER, THIS SIGNATURE SHALL INDICATE THAT THE APPLICANT SHALL BE PERSONALLY RESPONSIBLE FOR COMPLIANCE TO CITY ORDINANCES AND OTHER GOVERNMENTAL JURISDICTIONS.

Location of Sign Placement: _______________________________________________________________

Dates of Sale(s) ________________________________________________________________________

City of Clarkson Valley

636-227-8607 Phone    -    636-227-1914 Fax

cvcityhall@sbcglobal.net