Citizen Request for Services Form

2. Please use this form to get in touch with us or report an issue such as pothole or street light outtage! We appreciate your feedback. Please do not use this online form for police matters or an emergency. In an emergency, dial 911.

   Please use this form to get in touch with us or report an issue such as pothole or street light outtage! We appreciate your feedback. Please do not use this online form for police matters or an emergency. In an emergency, dial 911.
4. Reported location must be within the Easttown Township. Please be as specific as possible regarding the location or nature of request.
10. Contact Information
12. First Name*
13. Last Name*
15. Phone Number
16. Email Address*
18. Street Address:
20. Exact Location of Job Requested
22. Street Name, Address or Block Number*
24. Nearest Two Cross Streets
26. Nature of Request*
28. Department*

    Please select a department for the request

    1. Public Works
    2. Building
    3. Administration
    4. Other
30. Please Explain Other Department*
32. Upload a File
34. Comments
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit Submit and Print

* indicates a required field