TREE TRIMMING AND/OR REMOVAL CONSENT

Account #: _______________________ Daytime Phone: ___________________________

I,_________________________________ , give FreeState Electric Cooperative, Inc. permission to

£ TRIM _________________________ or £ REMOVE the trees at:
___________________________________________________________________________
(ADDRESS)

Remarks and/or instructions:__________________________________________________

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
CLEAN-UP: £ CO-OP £ LANDOWNER
If you checked CO-OP, would you like us to leave wood chips if available? £ YES £ NO
ADDITIONAL CLEAN-UP INSTRUCTIONS: _______________________________________
___________________________________________________________________________
Landowner agrees to hold harmless FreeState Electric Cooperative, Inc. and its trustees, officers, and agents and
employees in connection with the performance of the work performed by FreeState Electric Cooperative, Inc. in tree
trimming/or removal of trees and/or shrubs for the landowner.

_____________________________________________ ___________________________________________
Signature Date

_____________________________________________ ___________________________________________
Witness Signature Date

OFFICE USE:
_________________________________ _____________________________________
Date Completed Work Completed By

_________________________________ _____________________________________
Map Location District #