Form OC 100 Adopt-A-highway Permit Request - Illinois

Form OC100 is a Illinois Department of Transportation form also known as the "Adopt-a-highway Permit Request". The latest edition of the form was released in June 7, 2018 and is available for digital filing.

Download a PDF version of the Form OC100 down below or find it on Illinois Department of Transportation Forms website.

ADVERTISEMENT
Adopt-A-Highway Permit Request
The electronic version of this form is available on IDOT's website at:
http://www.idot.illinois.gov/about-idot/employment-opportunities/
community-involvement/index
Request (check one)
Permit Number (for renewals and information changes)
New
Renewal
Change of Information
Each volunteer group is responsible for a two-mile section of highway. (Section length may vary because of physical boundaries.)
Interstate highways and fully access-controlled freeways are NOT included in this program. The district coordinator shall approve sections
of highway available for adoption. Areas may be declared ineligible for adoption by the district for safety or other reasons.
1 st Choice
Highway Name/Number
From
To
County
2nd Choice
Highway Name/Number
From
To
County
Group Information
Group Name
State
Mailing Address
City
Zip Code
Illinois
Contact Person (1st)
Email
Phone
Contact Person (2nd)
Email
Phone
Sign Information
Name as it is to appear on signs (2 lines - maximum 15 characters and spaces per line). Adopt-A-Highway signs with permittee shall be
furnished, erected, and maintained by the district. No logos or slogans will be allowed on the signs. Signs and space shall be made
available to other groups when a permit is terminated or is not renewed.
Line 1
Expected Average Number of Workers
Line 2
Volunteer groups agree to remove litter from the assigned section of highway at least four times each year for a two-year period. In return
for this partnership, IDOT will provide roadside signs identifying your groups as an Illinois Adopt-A-Highway program participant. (IDOT
reserves the right to approve all messages on the signs and all group applications.) IDOT provides safety vests and trash bags to roadside
clean-up volunteers and removes the filled bags from the roadside the following pickup day.
Stolen/Vandalized Signs
IDOT Replaces A Stolen/Vandalized Sign Once Per 2-Year Period.
Mission Statement:
In the space provided below or as an attachment please clearly and concisely provide the department with the
objectives and benefits of the applicant organization.
OC 100 (Rev. 06/07/18)
Printed 10/24/19
Page 1 of 2
Adopt-A-Highway Permit Request
The electronic version of this form is available on IDOT's website at:
http://www.idot.illinois.gov/about-idot/employment-opportunities/
community-involvement/index
Request (check one)
Permit Number (for renewals and information changes)
New
Renewal
Change of Information
Each volunteer group is responsible for a two-mile section of highway. (Section length may vary because of physical boundaries.)
Interstate highways and fully access-controlled freeways are NOT included in this program. The district coordinator shall approve sections
of highway available for adoption. Areas may be declared ineligible for adoption by the district for safety or other reasons.
1 st Choice
Highway Name/Number
From
To
County
2nd Choice
Highway Name/Number
From
To
County
Group Information
Group Name
State
Mailing Address
City
Zip Code
Illinois
Contact Person (1st)
Email
Phone
Contact Person (2nd)
Email
Phone
Sign Information
Name as it is to appear on signs (2 lines - maximum 15 characters and spaces per line). Adopt-A-Highway signs with permittee shall be
furnished, erected, and maintained by the district. No logos or slogans will be allowed on the signs. Signs and space shall be made
available to other groups when a permit is terminated or is not renewed.
Line 1
Expected Average Number of Workers
Line 2
Volunteer groups agree to remove litter from the assigned section of highway at least four times each year for a two-year period. In return
for this partnership, IDOT will provide roadside signs identifying your groups as an Illinois Adopt-A-Highway program participant. (IDOT
reserves the right to approve all messages on the signs and all group applications.) IDOT provides safety vests and trash bags to roadside
clean-up volunteers and removes the filled bags from the roadside the following pickup day.
Stolen/Vandalized Signs
IDOT Replaces A Stolen/Vandalized Sign Once Per 2-Year Period.
Mission Statement:
In the space provided below or as an attachment please clearly and concisely provide the department with the
objectives and benefits of the applicant organization.
OC 100 (Rev. 06/07/18)
Printed 10/24/19
Page 1 of 2
Expected Dates of Pickup
(Enter one date for each period)
"Expected Dates of Pickup" will be assumed unless the Illinois Department of Transportation district office is notified 10 days in advance of
any deviation from the planned work dates entered for each period.
Year 1
Year 2
Period #1 (April-May)
Period #1 (April-May)
Period #2 (June-July)
Period #2 (June-July)
Period #3 (Aug-Sept)
Period #3 (Aug-Sept)
Period #4 (Oct-Nov)
Period #4 (Oct-Nov)
Electronic Signature
By checking this box and filling in my name, the Group acknowledges the conditions of the work, agrees to the terms and conditions set by
the Department and the Illinois Adopt-A-Highway Act and agrees to hold the State of Illinois and the State's agents or employees harmless
from any and all claims or actions resulting from the Adopt-A-Highway Program. The group representative is at least 21 years of age.
Group Representative's Name
Date
Submittal Instructions
1. Submit applications electronically by clicking the 'Email' button at the top of page one.
2. Submit hard copy applications to: Adopt-A-Highway Program
Illinois Department of Transportation
2300 South Dirksen Parkway, Rm 118
Springfield, IL 62764
(217) 557-3224
Permit Renewal
This permit may be renewed by filling out this form and checking the 'Renewal' box on page one and submitting to the Illinois Department
of Transportation on or before March 31 of the year after expiration. Follow Submittal Instructions above. With satisfactory completion of
the litter pickup the previous two years, IDOT may renew and issue a new permit for an additional eight periods.
For IDOT District Use Only
Maintenance Yard
Permit Number
Team Section
Maintenance Yard Phone Number
Permit Approved Date
Subsection
Signs Installed Date
Shoulder Miles
Expiration Date
The above information is complete and accurate.
March 31, 20
Date
District Coordinator
For IDOT State Coordinator Use Only
Date Received
Letter Sent Date
Printed 10/24/19
Page 2 of 2
OC 100 (Rev. 06/07/18)
ADVERTISEMENT
Page of 2