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Fix it Fairbury

2. Name*

3. Email Address*

5. Address

7. City

8. State

9. Zip Code

11. Phone Number

12. Fax Number

14. Date*
    Date

16. Issue*

    Please check button that identifies the issue you would like to report.

    1. Pothole

    1. Street Light Out

    1. Nusiance (select one below)

    1. Street Sign Down
19. Type of Nusiance

    1. Grass
    2. Structure
    3. Junk
    4. Vehicle

23. Upload photo of issue (optional):

25. Please provide a brief description of the issue:*

Leave This Blank:


26. 1. Receive email copy
27. Email address

    This field is not part of the form submission.

28. Submit Submit and Print

* indicates a required field