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2. Referral Source
   -- Select One --Non-profitStateCountyCityTownshipSchool

   Choose One
4. Submission Date
8. REFERRAL AGENCY
10. Department/Agency Name
12. Address1
14. Address2
16. City
17. State
18. Zip
22. PROJECT DATA
24. Project Title
26. Description
30. LOCATION INFORMATION
32. County
33. Township
35. Project Size
37. Crew Size Suggested
39. Estimated Completion Time (total hours)
41. Duration (check one)

    1. Periodic/Seasonal
    2. Continuous
43. Priority (check one)

    1. Low
    2. High
45. Estimate of Project Value (value to agency if done by contractor or agency)
49. SPECIAL REQUIREMENTS
51. Timeframe for Completion (seasonal)
53. Special Skills or Training Required or Provided for Crew Members
55. Special Tools or Equipment Required or Provided for Crew Members
57. Are there any special details (such as data privacy, right-to-know issues, health/safety hazards [i.e., chemicals], etc., which may require special planning, training, equipment, and/or consideration?

    1. Yes
    2. No
59. If yes, please explain
63. CONTACT INFORMATION
65. Project Contact Person
66. Phone Number
68. Address1
70. Address2
72. City
73. State
74. Zip
76. Before beginning project, who should the crew leader contact?
78. Name
79. Phone Number
81. Any projects undertaken by STS are done so with consideration to union contracts. Has the union been notified? If regular or seasonal employees would normally do this project, an explanation is necessary to gain union support.
83. Explanation
Leave This Blank:


85. 1. Receive an email copy of this form.
86. Email address

    This field is not part of the form submission.

87. Submit

* indicates a required field