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2. Purpose

   Use this form to report a pothole to the Village of Amityville Department of Public Works.

4. First Name*
5. Last Name*
7. Email Address
9. Daytime Phone*
11. Address*
13. City*
14. State*
15. Zip Code*
17. Location of Pothole*

    be as specific as possible. Please include street number (if known) and street name.

19. Attach Picture or File
Leave This Blank:


21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field