Work Zone Clearinghouse

Online Roadway Work Zone Memorial Name Submission Form

Criteria:
Fatality must have occurred In a roadway work zone. Submissions may include workers, pedestrians, motorists, law enforcement or public safety officials.

(1) Name Of Deceased:

(2) Date of Fatality:

(3) Date and Location of Fatality:

(4) The Person Named Above:

Pedestrian
Work Zone Worker
Motorist
Law Enforcement
Law EnforcementPublic Safety Official
Child

(5) Brief Biography of Victim:

Attach an Image:
(6) Brief Description of Work Zone Accident:

(7) Verification of above information is provided in the form of (please provide all available):

Official police accident report
Notarized employer affidavit (applicable in case of roadway workers, law enforcement officers, and emergency workers only)
Newspaper or media clipping

(may attach text or documentation)

Name of Applicant:

Address of Applicant:

Applicant’s email:

Applicant’s Daytime Telephone Number:

Date of Application:

(8) I certify I have obtained permission from the deceased’s family or former guardian to provide the above information, and for the deceased’s name to be listed on the National Work Zone Memorial. By providing this information, applicant shall indemnify and save and hold harmless American Road and Transportation Association.
and its officers, agents, and employees acting for ARTBA or The Foundation, against any liability, including costs and expenses. I further certify that all information provided is true and correct to the best of my knowledge. For motorist category only: I further certify that the individual named on this form was not under the influence of drugs or alcohol at the time of the fatality.

I Agree

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Saturday Vigil: 4:30 pm

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6654 Main Street
Wonderland, AK 45202
(513) 555-7856