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2. Today's Date
   Today's Date
4. Violation Date & Time*
   Violation Date & Time

   Violation Date & Time
5. Ticket Number*
9. First Name*
10. Last Name*
12. Date of Birth*
    Date of Birth
14. Address1*
16. Address2
18. City*
19. State*
20. Zip*
22. Email Address*
23. Telephone Number*
27. Violation Type*
    -- Select One --Property MaintenanceLandscapingPavement & Parking LotsVacant Structures/LandIllegal Land UsePermits
29. Upload supporting photos or documents
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31. 1. Receive an email copy of this form.
32. Email address

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