Name*

Date of Birth (MM/DD/YYYY)*

Township (check all that apply)*

Collins Franklin Grant Howard Indian Creek Lafayette Lincoln Milford

Nevada New Albany Palestine Richland Sherman Union Warren Washington

Residential Address*

City*

Phone Number (xxx) xxx-xxxx*

Number of Signs Requested*

None 1 2 3 4 5

For public safety notifications, how do you want to be contacted?

Email (please provide your email address)

Cell phone (Text message notification) xxx-xxx-xxxx

Cell Phone Provider (Required to receive text message notification)

Verizon US Cellular AT&T Sprint T-Mobile I-Wireless Straight Talk

If your cell phone provider is not listed above, please type it here.

I do not wish to be contacted

*Your personal information is used solely for the purpose of contact in the event that the Sheriff's Office needs to update Farm Watch members with public safety notifications. It will not be sold to any third party.