Nearest Street Address

Nearest Cross Street

Pole/Light Number

If address is not known, provide detailed description of the pole's location (For example, 2nd pole from the NE corner of 7th Street and Main Street):

Choose one or more options:
Burn-out
Cycles (turns on and off repeatedly)
Light burns 24 hours a day
Broken glassware
Water or debris in glassware
Pole is bent
Support arm is bent or broken
Multiple lights are out
Other (Please describe the damage below)

Please Provide the following information so that we may contact you, if needed, regarding this report

Name:

Email address:

Phone: