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SERVICE REQUEST SYSTEM

Complete the following. Fields marked with an asterisk (*) are required
	Service Request Type:	Pothole
	Description:	Report a pothole located on a public street
	Contact E-Mail:

To be notified by e-mail on this request please enter your contact e-mail above To file a request online: Please fill out the form below as completely as possible and click Submit. Or call: (937) 296-2472
		Contact Information (your information)
*	First Name:
*	Last Name:
	Street Address:
	City:
	State:
	Zip Code:
*	Contact Phone Number:
*	Street Name:
		Location of Pothole:(Please describe location in detail. Example direction of lane, intersections, approximate address)
*	Enter the location of the pothole:
		Select the Closest Intersection if Available

	Attach a Photo/File:
	Attach a Photo/File:
	Attach a Photo/File:
	Attach a Photo/File:
	Attach a Photo/File:
**** Please note that submission of this information is subject to the City's public records requirements and, therefore, will be available for release as public information. See below for the City of Kettering PRIVACY POLICY