2. Your Name:*
4. Your Address:*
6. City:
7. State:
8. Zip:
10. Preferred Telephone:*
12. Other Telephone:
14. Email Address:
16. Block Party Location:*
18. Date of Block Party:*
20. Estimated Start Time:*
21. AM or PM*
    -- Select One --AMPM
23. Number of People Expected:
25. Number of Barricades:*
    -- Select One --012
27. Streets Requested to Barricade:
29. Requested Drop Off Date:
31. Requested Drop Off Time:
32. AM or PM
    -- Select One --AMPM
34. Barricade Drop Off Location (street address):
36. Requested Barricade Pick Up Date:
38. Requested Barricade Pick Up Time:
39. AM or PM
    -- Select One --AMPM
41. Requested Barricade Pick Up Location (if different from drop off location):
43. Special Visit Requests (e.g. Fire or Police Department):
45. Other Comments:
47. Unless restricted by law, all correspondence to and from Roseville City government offices, including information submitted through electronic forms such as this one, may be public data subject to the Minnesota Data Practices Act and/or may be disclosed to third parties.
    
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49. 1. Receive an email copy of this form.
50. Email address

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