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2. Clean Pavement Initiative Professional Commitment Form
4. Date*
   Date
6. Professional Contact Information
8. Sealant Industry Professional Company Name*
10. Contact Name*
12. Address*
14. City*
15. Zip Code*
17. Phone Number*
18. Email*
20. Clean Pavement Commitment

    1. I commit to offering, educating, and tracking the application of asphalt-based sealants.

    By checking this box, I agree to offer asphalt-based sealant (i.e. asphalt emulsion) as an option to my customers and educate them by providing the Clean Pavement Initiative program brochure supplied by the City. I also agree to provide annual data to the City on the amount of coal-tar based and asphalt-based sealant applied in Springfield so the effectiveness of this program can be tracked over time. This voluntary commitment does not prevent the sale or use of other types of sealant.
22. Submit Comments or Feedback about this Program
23. Brochures
    -- Select One --2550100150200

    Estimated Need
25. Once you have submitted this form, City staff will follow up with you to supply brochures for your use.
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field