2. First Name*
3. Last Name*
5. Phone number*
   Please provide a contact number in case we have questions
6. Email*
8. Date you noticed pothole*
   Date you noticed pothole
10. Pothole address*
12. Location on the road*

    1. Right lane
    2. Left lane
    3. Center turn lane
    4. Centerline
    5. Shoulder
    6. Intersection
14. Approximate size*

    1. Small (up to 6 inches in diameter)
    2. Medium (6 to 12 inches in diameter)
    3. Large (greater than 12 inches in diameter)
16. Additional comments
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18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

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