Form Center

2. 
3. County of Humboldt
   Department of Public Works. .. 1106 Second Street .. ... ... . .. Eureka, CA 95501-0579 .. Attention: Engineering Division
5. Comment Card
   The Department of Public Works encourages public comment on our projects. Your input is important in the development of a project. Your written comments will become part of the public record and will be considered in developing the environmental documents.
7. Project Name:*
8. Contract No:
10. Level of Support

    Please indicate your overall level of support for this project.

    1. High
    2. Medium
    3. Low
12. Comments
    Please write you comments above.
14. Date
    Date
18. Follow Up Questions:

    1. Yes

    1. No

    May we contact you to respond to your comments and concerns or to seek additional information regarding this project?
20. Contact Information
    The following information is optional.
22. Name:
23. Affiliation (If applicable):
25. Address:
27. City:
28. State:
29. Zip Code:
31. Phone:
32. Email:
36. Public Participation Survey:
    The following information is being collected by the Department of Public Works in order to comply with Title VI of the Civil Rights Act of 1964. Please take a few moments to complete the following questions. The data you provide will enable the Department to identify residents and communities impacted by federally funded projects/or activities. Please select the choice from the pull down menu that best describes you. Submittal of this information is voluntary. Thank you.
38. Sex:
    -- Select One --MaleFemale
39. Ethnicity:
    -- Select One --Hispanic/LatinoNon_Hispanic/Latino
40. Race:
    -- Select One --American Indian or Alaskan NativeBlack or African AmericanNative Hawaiian or Other Pacific IslanderAsianWhiteOther
42. Disabity:
    -- Select One --YesNo
43. Age:
    -- Select One --Under 40 years old40 years old and older
44. Income:
    -- Select One --$22,050 or LessOver $22,050
46. Language:
    What language is primarily spoken in your household?
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit Submit and Print

* indicates a required field