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2. First Name*
3. Last Name*
5. Date*
   Date
6. Email*
8. Address*

   Please enter the approximate address of the pothole

10. City
11. State
12. Zip Code
14. File

    If you would like to attach a picture of the pothole, please do so.

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16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

* indicates a required field