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Pot Hole Repair Request Form

Please complete the following information:

Note: * indicates required fields for submitting the request

Date*
Name*
Address*
City*
State*
Zip*
E-mail
Home Phone*
Work Phone
 
Please provide accurate information about where the pothole is located - street name, block number, house number, inbound lanes, outbound lanes, etc. Any information that can help repair crews find it quickly is needed:*
 
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