Report a Pothole to
Public Works

GENERAL INFORMATION
  First Name*
  Last Name*
  Address
  City
  State
  Zip Code
  Home Phone
  Business Phone
  Your E-mail Address
  Date Encountered*
POTHOLE INFORMATION
  Location type*:
(Select One)		 Address - A
Intersection - B
Between intersections - C
A
 Enter Address (if you selected "address" above)
Address 1:
  Address 2:
  City, State: Worth, Illinois
B
 Enter Intersection (if you selected "intersection" above)
  Intersection:
C
 Enter Intersections A & B (if you selected "between intersections a & b above)
  Intersection A:
  Intersection B:
  Direction of Lane: