Form DACS-11069 "Florida Champion Tree Program Property Owner's Agreement" - Florida

Form DACS-11069 or the "Florida Champion Tree Program Property Owner's Agreement" is a form issued by the Florida Department of Agriculture and Consumer Services.

Download a PDF version of the Form DACS-11069 down below or find it on the Florida Department of Agriculture and Consumer Services Forms website.

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Download Form DACS-11069 "Florida Champion Tree Program Property Owner's Agreement" - Florida

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ADAM H. PUTNAM
COMMISSIONER
Florida Champion Tree Program Property Owner’s Agreement
I, ____________________________________ (printed name), as a voluntary participant in the
Florida Champion Tree Program, do hereby give the Florida Department of Agriculture and
Consumer Services (the “Department”) permission to display on the Department’s internet website
the following information regarding the champion tree(s) on my property: species name, size
measurements, and county where the tree(s) is/are located.
I acknowledge that the Department will retain the following information in order to revisit the tree(s)
and update their records in the future: my contact information, including name, mailing address,
phone number, and email address; a map or directions to the tree location; and the latitude and
longitude where each tree is located. The display of my information on the website shall be subject to
my wishes indicated below. The Department will prominently display verbiage on the website
instructing interested parties who wish to visit my champion tree(s) to request permission from me
either by phone or in writing before attempting to do so.
I acknowledge that all information provided to the Department, including, but not limited to, the
location of the champion tree and my contact information, is a public record subject to disclosure in
accordance with chapter 119, Florida Statutes, regardless of whether the information is displayed on
the internet website.
In consideration of the above, I agree to hold the Department, its employees, and agents harmless
from any and all claims, liabilities, causes of action or damages whatsoever, including all costs and
attorney’s fees, arising from the display of the information and photographs agreed to herein on the
Department’s internet website.
I do_____ do not_____ (check one) give the Department permission to display my contact
information, including address, telephone number and email address, on the website, as well as a map
or directions to the tree location, and the latitude and longitude where each tree is located.
I do_____ do not_____ (check one) give the Department permission to display one or more
photographs of my tree(s) on the website.
I do_____ do not_____ (check one), as parent or legal guardian of the minor(s) shown in the above
referenced photos, approve the above release and waive any rights in the premises.
Property Owner’s Signature:______________________
Date: __________
Tree ID#:
Species:
County:
DACS-11069 Rev. 7-16
ADAM H. PUTNAM
COMMISSIONER
Florida Champion Tree Program Property Owner’s Agreement
I, ____________________________________ (printed name), as a voluntary participant in the
Florida Champion Tree Program, do hereby give the Florida Department of Agriculture and
Consumer Services (the “Department”) permission to display on the Department’s internet website
the following information regarding the champion tree(s) on my property: species name, size
measurements, and county where the tree(s) is/are located.
I acknowledge that the Department will retain the following information in order to revisit the tree(s)
and update their records in the future: my contact information, including name, mailing address,
phone number, and email address; a map or directions to the tree location; and the latitude and
longitude where each tree is located. The display of my information on the website shall be subject to
my wishes indicated below. The Department will prominently display verbiage on the website
instructing interested parties who wish to visit my champion tree(s) to request permission from me
either by phone or in writing before attempting to do so.
I acknowledge that all information provided to the Department, including, but not limited to, the
location of the champion tree and my contact information, is a public record subject to disclosure in
accordance with chapter 119, Florida Statutes, regardless of whether the information is displayed on
the internet website.
In consideration of the above, I agree to hold the Department, its employees, and agents harmless
from any and all claims, liabilities, causes of action or damages whatsoever, including all costs and
attorney’s fees, arising from the display of the information and photographs agreed to herein on the
Department’s internet website.
I do_____ do not_____ (check one) give the Department permission to display my contact
information, including address, telephone number and email address, on the website, as well as a map
or directions to the tree location, and the latitude and longitude where each tree is located.
I do_____ do not_____ (check one) give the Department permission to display one or more
photographs of my tree(s) on the website.
I do_____ do not_____ (check one), as parent or legal guardian of the minor(s) shown in the above
referenced photos, approve the above release and waive any rights in the premises.
Property Owner’s Signature:______________________
Date: __________
Tree ID#:
Species:
County:
DACS-11069 Rev. 7-16
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