Title *

Mr. Mrs. Ms.

Name - Last Name (Interrest) *

I.D. number. *

Contact number. *

Places/stresssing of public power. *

Electrical number (if you know)

Number of Lost (stilver/tree) *

A broken nature. *

--please choose the symptom --Light is off or does not turn onFlickering lightFlickering lightDamaged or detached light fixtureLeaning or fallen utility poleBroken or sagging power cableOther (please specify in more detail)

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