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Highway Department Request For Service

2. Highway Department Request For Service
   PLEASE NOTE: ALL fields require an answer. You will not be able to submit the form until ALL fields are completed.

   PLEASE NOTE: ALL fields require an answer. You will not be able to submit the form until ALL fields are completed.

4. Your First Name*

5. Your Last Name*

7. Your HOME Address*

9. Your City*

10. Your State*

11. Your Zip*

13. Daytime Phone Number*

14. Your Email Address*

16. Is your request for service on the road or street on which you live?*

    1. Yes

    1. No

18. If no, please tell us on what road or street the issue or problem is. Please be as specific as possible. *

    For example: "On Meridian Road between 600 North and 700 North" or "the intersection of Smoke Road and Division Road"

20. What type of service are you requesting?*

    1. Pot Hole Repair
    2. Missing Traffic Sign

    1. New Traffic Sign
    2. Plowing and/or Salting

    1. Mailbox or Right Of Way Damage
    2. Other

22. For information about Mailbox and Right of Way damages and filing a claim, please go here:
    Damage & Claim Submission Information

    Please go to the link above and discontinue submission of this form

24. Please tell us as much as possible about the problem or issue you are requesting service for.*

26. After you have completed all fields on this form, please click on Submit or Submit & Print (if you want to keep a printed copy). After you click on Submit or Submit & Print, you will be redirected to a submission confirmation page. If you are unable to submit, it is likely that you failed to complete a field on this form.

Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit Submit and Print

* indicates a required field