2. First Name
3. Last Name
5. What is the problem?*

   1. Pothole
   2. Deep ruts
   3. Uneven pavement
6. Location*
   Please provide nearest address or description so our crew can find the issue
8. Other details
10. Photo upload (optional)
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12. 1. Receive an email copy of this form.
13. Email address

    This field is not part of the form submission.

14. Submit

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