Utility Pole Termination Report Form
Please complete this form to report the termination, removal, or disconnection of a utility pole. All information is required to ensure proper documentation and follow-up.
Reporting Person's Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Termination/Removal
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Utility Company Name
*
Pole Location (Address or GPS Coordinates)
*
Reason for Termination/Removal
*
Please Select
Scheduled Replacement
Damaged/Unsafe
Obsolete/No Longer Needed
Relocation
Other
Description of Work Performed
*
Status After Removal
*
Please Select
Pole Completely Removed
Pole Cut but Base Remains
Pole Disconnected Only
Other
Upload Supporting Photos or Documents (optional)
Upload a File
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of
Submit Report
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