236-26 EZ Speed Study Program and Application - Final.pdf

3 | P a g e EZ Speed Study Program Application and Agreement Form _____________________________ ___________________________________ Phone Number and extension (if any) Email Program Coordinator (if different from above): ___________________ _______________________ _______________________________ First Name Last Name Title/Position ____________________________________ _______________________________ Street Address City/State/Zip _____________________________ _______________________________ Phone Number and extension (if any) Email Proposed Location/s for Installation: ____________________________________________________________________________ ____________________________________________________________________________ Street Name or Number as applicable * Road Jurisdiction (select one) ___Municipal ___County* ___State* * If you wish to do a speed study on a State or County road, you must secure written approval and submit with this application. Direction of Traffic you want to record (select up to two) __North __South __East __West Please describe the specific need for the device at this location (example, school or park nearby, speeding complaints, short-cut street, bottom of a hill) ____________________________________________________________________________ ____________________________________________________________________________ ________________________ ____________________________ _________ Applicant/Borrower Name Signature Date