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2. Your First Name*
3. Your Last Name*
4. Phone Number*
   xxx-xxx-xxxx
6. Your email*
8. Address1
10. Address2
12. City
13. State
14. Zip
16. Type of traffic problem*

    1. Speeding
    2. Stop Sign/Traffic Light
    3. Parking
    4. Abandoned Vehicle
    5. Other:
18. If other, please specify violation type
20. Location of Traffic Problem
22. Time this problem occurred/occurs*
23. AM / PM

    1. AM
    2. PM
24. Date(s) of this problem*
26. Additional information
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

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