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2. Disclaimer
   Information submitted on this form will be sent via unsecured email. To protect sensitive information, do not enter the following items or similar information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, credit card numbers, medical information, passport numbers, and passwords. Please review our privacy policy located at www.jeffco.us/privacy. By submitting this form, you acknowledge and accept the terms listed in the privacy policy.
6. Return to Roadside Memorial Signs Page
   Link to page
8. Mail-in PDF Application Form
   Link to PDF application form

   If you would prefer to mail the application, please complete, print, and sign the PDF version. Mail the application with supporting documents to Transportation and Engineering, 100 Jefferson County Parkway, Suite 3500, Golden, CO 80419.
10. Applicant Information
12. Name of person or group applying for sign*
14. Phone Number*
15. Email Address*
17. Mailing Address
19. Address Line 2
21. City
22. State
23. Zip Code
27. Crash Information
29. Date of fatal crash*
    Date of fatal crash
30. Location of crash*
32. Investigating law enforcement agency
33. Name of the driver on the crash report*
35. Crash Report Number
36. Crash Report
    If you have a copy of the crash report, you may upload it here.
38. Victim's name as it appears on the crash report*
40. Second victim's name as it appears on the crash report (if applicable)
42. Third victim's name as it appears on the crash report (if applicable)
46. Sign Selection
    Signs can be selected from the following:
48. 
49. 
50. 
51. 
53. Select Roadside Memorial Sign Message*

    Please choose one.

    1. DON'T DRINK AND DRIVE (note specific requirements below)
    2. PLEASE DRIVE SAFELY (for any fatalities)
    3. PLEASE RIDE SAFELY (for motorcycle / bicycle fatalities)
    4. PLEASE BUCKLE UP (for fatalities where victim was not wearing a seat belt)
55. Requirements for DUI related crashes:
    Signs titled "DON'T DRINK AND DRIVE" are for Driving Under the Influence (DUI) related crashes where the driver was convicted of violating Colorado DUI laws. Memorial signs will not be erected for deceased drivers involved in fatal crashes whose toxicology reports show a violation of Colorado DUI laws without written consent from any other victim(s) or their immediate families.
57. Permission to install DON'T DRINK AND DRIVE sign
    Written consent from any other victim(s) or their immediate families may be uploaded here.
59. 
60. Each sign will be accompanied by an IN MEMORY OF sign. A maximum of three names may be placed on a sign.
62. Victim's name as it should appear on the sign*
64. Second victim's name as it should appear on the sign (if applicable)
66. Third victim's name as it should appear on the sign (if applicable)
68. Additional Comments
72. Acknowledgment
    Jefferson County, Colorado and the applicant agree to and approve the use of electronic signatures for purposes of this application. All use of electronic signatures shall be governed by the Uniform Electronic Transactions Act, C.R.S. §§24‐71.3‐101 to ‐121.
74. Acknowledgment agreement *

    Do you agree to the above acknowledgment?

    1. I agree.
76. Applicant Signature*
78. Relation to Victim*
    If the applicant is not an immediate family member of the victim, write "Sponsor" and attach written consent from an immediate family member, listing their relationship to the victim, naming the applicant as an authorized representative, and indicating who should be contacted when the sign is removed.
80. Written consent from the victim's family
    If you are a sponsor, you may upload written consent from the victim's immediate family here.
Leave This Blank:


82. 1. Receive an email copy of this form.
83. Email address

    This field is not part of the form submission.

84. Submit

* indicates a required field