Form Center

2. Subdivision
   Please enter the name of your subdivision
3. Does your subdivision have a mandatory homeowners association?*
   -- Select One --YESNO
5. Board President
   Please enter the Homeowner Association President's name
6. Project Contact First Name*
   Please enter the first name of the person responsible for this project
7. Project Contact Last Name*
   Please enter the last name of the person responsible for this project
9. Project Contact Phone *
10. Project Contact Email
12. Number of Medallions Requested*
    -- Select One --102030405060708090100
14. I/we hereby agree that: *

    Checking the boxes, electronically signing and submitting this form to the Stormwater Division constitutes acceptance of the following terms and conditions:

    1. I am an authorized Homeowners Association Board Member or designated representative with approval to acquire storm drain medallions from James City County
    2. I acknowledge that the storm drain medallions will be installed within 60 days of receipt
    3. I will notify residents within the subdivision the purpose of the storm drain medallions
    4. I/we will notify James City County by calling 757-259-1446 when the storm drain medallions have been installed
    5. I/we grant James City County permission to inspect the storm drain medallions
16. Electronic Signature
Leave This Blank:


18. Submit

* indicates a required field