1

Requestor's Name

 *

Requestor's Name

First Name

Last Name

2

Address

Address

Street Number

Street Name

City

Zip Code

3

Telephone Number

 *

Telephone Number

Best phone number to reach youext.

Secondary Phone Number; if applicableext.

4

Email

Email Address

5

Is there a pole at the proposed location?

Is there a pole at the proposed location?

Yes

No

6

If yes, what is the pole number (tagged on the pole)?

Pole #

7

Location and/or Intersection

Provide the location of where you would like the new street light pole to be installed.

8

Reason for streetlight request

Please provide the reason why you feel a new streetlight is necessary.

STAFF USE ONLY:

Request Received By: ______________________________________________

Date Received: ____________________________________________________

Approved: ______   Denied: ______

If denied, list reason: _____________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

City of Fort Lauderdale
Parks and Recreation Department - Facilities Maintenance
701 S. Andrews Ave
Fort Lauderdale, FL 33316

Email: facilities@fortlauderdale.gov

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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