DAMAGE TO UNDERGROUND FACILITIES
RECEIVING INFORMATION FORM
FOR MEMBERS ONLY
Member Code:
Database Information:
Contact Name:
Title:
Physical Address:
City:
State:
North Carolina
Other
Zip:
Phone: (include area code)
Extension:
Fax Number:
(include area code)
Email Address:
Location of Receiving Address:
Name:
Title:
Physical Address:
City:
State:
North Carolina
Other
Zip:
Phone: (include area code)
Alternate Contact Name:
Alternate Contacts Phone Number:
PRIMARY Email address for RECEIVING Transmissions:
ALTERNATE Email address for RECEIVING Transmissions
(if available)
Form Completed By:
Name:
Title:
Phone: (include area code)
Please contact Lesley Brady at (336) 855-5760 with any questions you may have.
