City of Montgomery District 4

district4@montgomeryal.gov

334-625-2101

District 4 Clean a Half Mile Bring a Smile Application Form

Phone Number

Gender

Male

Female

Do you have any medical conditions that will prohibit you from working outside?

Yes

Are you physically able to walk a mile?

Yes

Can you lift at least 15 pounds?

Yes

Do you have reliable transportation?

Yes

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.