2. First Name
3. Last Name
5. Phone Number
7. Fill in as much of the following as you can to identify your physical address for 9-1-1:
9. House Number
10. Street Name
12. Municipality
    -- Select One --Ashley BoroAvoca BoroBear Creek TwpBear Creek Village BoroBlack Creek TwpBuck TwpButler TwpConyngham BoroConyngham TwpCourtdale BoroDallas BoroDallas TwpDorrance TwpDupont BoroDuryea BoroEdwardsville BoroExeter BoroExeter TwpFairmount TwpFairview TwpForty Fort BoroFoster TwpFranklin TwpFreeland BoroHanover TwpHarvey's Lake BoroHazleton CityHazle TwpHollenback TwpHughestown BoroHunlock TwpHuntington TwpJackson TwpJeddo BoroJenkins TwpKingston BoroKingston TwpLaflin BoroLake TwpLarksville BoroLaurel Run BoroLehman TwpLuzerne BoroNanticoke CityNescopeck BoroNescopeck TwpNew Columbus BoroNewport TwpNuangola BoroPittston CityPittston TwpPlains TwpPlymouth BoroPlymouth TwpPringle BoroRice TwpRoss TwpSalem TwpShickshinny BoroSlocum TwpSugarloaf TwpSugar Notch BoroSwoyersville BoroUnion TwpWarrior Run BoroWest Hazleton BoroWest Pittston BoroWest Wyoming BoroWhite Haven BoroWilkes Barre CityWilkes Barre TwpWright TwpWyoming BoroYatesville Boro*Do Not Know

    All areas of Luzerne County fall into a municipality. If you are not sure of your municipality, please select "*Do Not Know"
13. Return email
    Type your return email here for your reply email or follow up questions from the Data Department if we need more information.
15. Describe your location
    Explain your location the best you can. Include a section of town, streets near you, or any other identifiable landmarks you may be near.
17. The 9-1-1 Data Department will follow up with an email or phone call to confirm your physical address when calling 9-1-1 for emergencies
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19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit Submit and Print

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