2. (includes plowing, snow and ice maintenance, pothole/pavement, street sweeping, etc.)

4. Contact Information
6. First Name*
7. Last Name*
9. Email Address*
10. Phone Number*
14. Description
16. Type of Concern
    -- Select One --Plowing/Snow/Ice MaintenancePothole/PavementStreet Light OutageStreet ParkingStreet SweepingOther
18. Description*
20. Location Information
22. Location Name
24. Address
26. City*
27. State*
28. Zip Code*
    -- Select One --554345544955014
30. Upload photo(s)?*

    1. Yes
    2. No
32. Upload Photo
34. Add another photo?*

    1. Yes
    2. No
36. Upload Photo
38. Add another photo?*

    1. Yes
    2. No
40. Upload Photo
42. Add another photo?*

    1. Yes
    2. No
44. Upload Photo
48. Would you like to sign up for Emergency Notifications from the City of Blaine?*

    1. Yes
    2. No
50. Home Address*
52. City*
53. State*
54. Zip Code*
    -- Select One --554345544955014
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit

* indicates a required field