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2. Name*

   *Form must be completed by the property owner

3. Email Address*
5. Address*
7. City
8. State
9. Zip Code
11. Phone Number*
13. Choice of Color for House Numbers*
    -- Select One --BlackWhite
14. Implementation of Numbers*
    -- Select One --Owner to Place on HomeVolunteer to Place on Home
16. Location on Exterior for Numbers*

    Specify where you would like the numbers placed on your residence (e.g., next to front door, above garage, etc.)

18. Photo of Outside of Home
20. Liability Waiver

    I, the undersigned, understand that the Clinton, Iowa, Fire Department is providing and installing house numbers as a public service in the interest of encouraging fire/life safety and helping to prevent needless injury and/or loss of life and property.

    In exchange for accepting free house numbers and their installation, I hereby agree never to make any claim or demand or file any lawsuit against the City of Clinton, Iowa, the Clinton, Iowa Fire Department, or any individual employee, agent, contractor, or volunteer of the City of Clinton, Iowa who is involved with the Minutes Matter Program.  I hereby forever waive all claims arising out of any injuries, deaths, damages, costs, or expenses suffered by me owing to the installation of house numbers, or activities reasonably associated with the same.  

    It is exclusively my responsibility to clearly communicate the location where the numbers are to be installed, so as to be plainly and easily visible from the public roadway, and further to direct the method of installation which, in my exclusive judgment, will cause the house numbers to be firmly attached without damaging my home. 

    I hereby waive any cause of action that I may have now or in the future or that anyone else may have by or through me, arising out of the installation of house numbers.  This release is binding on my Estate and any heirs, successors and assigns I may have who may assert any claim on by behalf. 

22. Name*

    By typing your name you have read, fully understand and agree to the liability waiver. 

23. Date*
    Date

    Date
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field