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2. First Name
3. Last Name
5. Street Address
7. Type of Light Pole*

   1. Decorative
   2. Standard Cobrahead
   3. Don't Know
8. Location of the pole and if known, the pole #*
10. Do you want to receive followup from DPW staff?

    1. Yes, I would like to know the status
    2. No, just fix it
12. If you answered Yes to the above question, please provide contact information:
14. After you submit your request:
    Once DPW receives the request the maintenance contractor will be notified. Repairs can be made in as little as 24 hours or may take longer depending on the day, time, location, weather conditions, and availability of replacement parts. If after 2 weeks the light is still not functioning please feel free to follow up with DPW directly at (413) 567-3400.
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16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

* indicates a required field