Your Name: 
             
	  Address: 
             
       Home Phone: 
       
   Business Phone: 

      Your E-mail: 

Graffiti Location:

Address or Cross-Streets:

Type of surface where graffiti is painted (i.e., brick wall, cinder block, sidewalk, wood, tree, etc.:

Waiver on file? Yes No

Sent waiver on (date):

Received waiver on (date):

Additional Information: