Road Maintenance Service Request Application

Please fill out the following application in order to process your service request

Name


Street Address


City / State / Zip Code


Phone Number


E-mail Address

Location of Maintenance


Between


And


Township/City/Village

Reason
Hot Mix Asphalt Patching Concrete Blow-ups Bridges Brush Removal/Trimming Catch Basins Chuckholes Chloride Cleanup Concrete Patch Culverts Debris Ditching Fences Flooding Grading Gravel Guardrail Hold Harmless Agreement Icy Roads Limb Removal/Trimming Mail Boxes Concrete Grinding/Milling Mowing Other Concrete Raising Salting Shoulders Snow Plowing Tree Stumps

Remarks