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2. Name of Person or Group applying for the Sign*
3. Daytime Phone*
5. Email Address*
7. Mailing Address*
8. Mailing Address 2
10. City*
11. State*
12. Zip*
14. Date of fatality (ie: 00/00/00)*
15. Location of fatality (Street, hundred block)*
17. County*
18. Upload a copy of the official police report*
20. Name of victim as it should appear on the sign*
21. Name of Victim as it appears on the Accident Report*
23. If there was more than one victim in the accident which you would like on the sign, please include those names here
25. Investigating Law Enforcement Agency*
26. Name of Driver on the Accident report*
28. Roadside Memorial Sign message to be included on the sign (Please choose one)*
    -- Select One --Don't Drink and Drive (Note specific requirements above)Please Drive Safely (for any fatalities)Please Ride Safely (for motorcycle/bicycle fatalitiesPlease Buckle Up (for fatalities where victim was not wearing a seat belt)
29. Preferred sign location (Please choose one)*
    -- Select One --Location as shown on the accident report (Provided by City, or State)Location as shown on the attached sketch (provided by applicant)

    City of Brighton will work with applicant to position the signage as close as possible according city signage regulations.

31. Victims immediate family electronic signature(s): typed name*
33. Applicant signature: (electronic)*
35. Date Submitted:
Leave This Blank:


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

    This field is not part of the form submission.

39. Submit

* indicates a required field