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2. Code Violation
4. Reporting Party Information (Confidential)
6. First Name*
7. Last Name*
9. Address1*
11. Address2
13. City*
14. State*
15. Zip*
17. Phone Number*
18. Email Address*
20. Signal / Light Information
22. Complaint Applies to*

    1. Traffic Signal

    1. Street Light

    1. Pothole
24. Location Address or Cross Streets*
26. Pole Number*

    Please provide the 5 digit pole number located approximately 6 feet on the face of the pole. If there is no number, just write N/A. 

27. Describe the Issue*
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29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field