Rest Area Activities Program Application

Group Name:
Tax Exempt Number:
501(c)-3 Status:
Address:
Day Telephone:
Rest Area Activities Chair Person:
E-Mail:
Rest Area Name:

Name of Rest Area (Check One):

Eastbound
          Westbound
          Northbound
Southbound

Dispensing Dates Requested (from 1 to 3 contiguous days):

Preferred Dates: To:
Alternate Dates: To:

Hours of Operation (daylight to dark daily minimum):

From:

To:

Number of Volunteers Working (at one time):