Banner Installation

Not for private or benefit

Not for private events or benefit
Applications should be submitted 30 days prior to installation

Applicant First Name (Value Required)

Applicant Last Name (Value Required)

Name of Organization

City (Value Required)

Zip Code (Value Required)

Phone #

Email Address

Please Confirm Email Address

County Roadway and Location of Event

Between these cross streets

Date of Installation

Expected format: MM/DD/YYYY

Dates banner(s) will be hanging

Description of Event

Required With Local Authorities

Coordination is required with local authorities:

Local Municipality

A certificate of liability insurance is required with Nassau County DPW as the certificate holder indemnifying the county against any and all claims arising from the hanging of the aforesaid banner(s)

Attach insurance certificate here (Value Required)

The department requires pole attachment approval from PSEG Long Island for which poles are to be utilized for attaching the banner(s) in question and our understanding of whose installation it will be by the local municipality

Attach approvals here (Value Required)

It is necessary to ensure the safety of the traveling public that the banner(s) be installed at a height of no less than 16’-0” over the roadway and that this clearance is maintained for the period that the banner(s) are in place

Title (Value Required)

* Click and drag your mouse in the box above to draw your signature.

Not for private or benefit

Banner Installation

Insurance Certificate

Pole Attachment Approval

Applicant Signature