Name(Required) First Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)No spray area description(Required)Please be as descriptive as possible using directions of east, west, north and south: Consent(Required) 1. Owner will comply with the Indiana laws regulating noxious weed control and the BCREMC’s Spraying Program Policy provisions regarding a no spray provision by taking the necessary steps to control noxious weed on the right-of-way located on Owner’s property. 2. Owner will control brush, trees and noxious weeds on said right-of-way. 3. Owner will assist BCREMC employees in identifying areas not to be sprayed. 4. In consideration of Owner’s desire and willingness to maintain the applicable rights-of-way, BCREMC will refrain from spraying in those locations properly designated. 5. Owner agrees and understands that failure to maintain the brush, trees or weeds under said right-of-way cause this agreement to be null and void, at which time BCREMC will take steps to have the right-of-way treated. Owner further agrees to indemnify and hold harmless BCREMC for any and all injury to persons or property that may occur as a result of Owner’s maintenance efforts on right of way. I hereby verify the information to be true and complete. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Electronic Signature (Full Name)(Required) EmailThis field is for validation purposes and should be left unchanged.
