Referral Source    Choose One DNR County City Township School Non-Profit Other State Agency        Submission Date: 1/26/2015

Department/Agency Name  
Address  
City    State   Zip Code  

Project Title  

Description  

County   Aitkin Anoka Becker Beltrami Benton Bigstone Blue Earth Brown Carlton Carver Cass Chippewa Chisago Clay Clearwater Cook Cottonwood Crow Wing Dakota Dodge Douglas Faribault Fillmore Freeborn Goodhue Grant Hennepin Houston Hubbard Isanti Itasca Jackson Kanabec Kandiyohi Kittson Koochiching Lac qui Parle Lake Lake of the Woods Le Sueur Lincoln Lyon McLeod Mahnomen Marshall Martin Meeker Mille Lacs Morrison Mower Murray Nicollet Nobles Norman Olmsted Ottertail Pennington Pine Pipestone Polk Pope Ramsey Red Lake Redwood Renville Rice Rock Roseau St. Louis Scott Sherburne Sibley Stearns Steele Stevens Swift Todd Traverse Wabasha Wadena Waseca Washington Watonwan Wilkin Winona Wright Yellow Medicine    Township  
Section      Range  

Project Size (Acres, Feet, etc)  

Crew Size Suggested  

Estimated Completion Time (total hours)  

Duration (check one)   Periodic/Seasonal        Continuous

Priority (check one)   Low     High

Estimate of Project Value (value to agency if done by contractor or agency)

Time frame for completion (seasonal)  

Special skills or training required or provided for crewmembers  

Special tools for equipment required or provided for crewmembers  

Are there any special details such as data privacy, right to know issues, health/safety hazards (i.e.,chemicals), etc., which may require special planning, training, equipment, and/or consideration?  yes   no

If yes, please explain

Project contact person        Phone  

Address  
City    State   Zip Code  

Before beginning project, who should the crew leader contact?
Name       Phone  

Any projects undertaken by STS are done so with consideration to union contracts.  
Has the union been notified?  If regular or seasonal employees would normally do this project, an explanation is necessary to gain union support.

Explanation

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