Pothole Submission Form

Welcome and thanks for participating. You can send us photos and videos you shot yourselves or upload your videos directly to YouTube and send us the link. If you need any help submitting let us know.

Items marked with the * are required for submission into the contest.

Give your submission a short title (ex: "HUGE pothole on Salt Springs Road!"):

*

An address near the pothole (not required but it helps us map the location):

*

The location of the pothole if available:

City you found the pothole in.

*

Zip code:

Latitude (if you know it):

Longitude (if you know it):

Photo:

Youtube ID (if you shot your own video and can't get it uploaded, let us know:

Your name (first name only or name and initial is fine):

*

Your email (Only in case we need to contact you regarding your submission):

*

Damage done to your car:

Your location (No home addresses please):

Your comments:

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