Carroll EMC - Application Form

Report Street/Security Light Problems

Thank you for helping us find street lights and security lights that are out or are malfunctioning. We ask for your name and phone number in case we need more information to help fix the problem. Just complete the form then click on the submit button. Our crews will see that the light(s) are repaired as quickly as possible. If you're reporting a hazardous condition please call us.

Tell us who is reporting the problem:

Your Name:	*
Street Address:
City:	State: Zip:
Telephone:	* Cellphone:
Email:

What type of problem are you reporting?

Describe the problem you are reporting in more detail:

What is the address or closest address of the problem you are reporting?

Address Number:
Street Name:
City:
The problem light is located to the	of the address.

If no address is available, please tell us the name of the street and which side of the street the light is on.

Is there anything else you would like to add?

Carroll EMC does not reveal any personal information that users provide to us through our Web site to any third party. All information provided by customers on this form is kept strictly confidential and secure to prevent unauthorized use of personal information.

Single light out	Broken glass
Multiple lights out	Open, broken, or missing light fixture
Light cycling on and off	Damaged pole
Light flickering	Exposed wires
Light on during daylight hours	Other