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Roadside Memorial Sign Application

  1. 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 By submitting this form, you acknowledge and accept the terms listed in the privacy policy.
  2. Applicant Information
  3. Crash Information
  4. If you have a copy of the crash report, you may upload it here.
  5. Sign Selection
    Signs can be selected from the following:
  6. Image of example Don't Drink and Drive sign.
  7. Image of example Please Drive Safely sign.
  8. Image of example Please Ride Safely sign.
  9. Image of example Please Buckle Up sign.
  10. Select Roadside Memorial Sign Message*
    Please choose one.
  11. 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.
  12. Written consent from any other victim(s) or their immediate families may be uploaded here.
  13. Image of example In Memory Of sign.
  14. Each sign will be accompanied by an IN MEMORY OF sign. A maximum of three names may be placed on a sign.
  15. 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.
  16. Acknowledgment agreement *
    Do you agree to the above acknowledgment?
  17. 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.
  18. If you are a sponsor, you may upload written consent from the victim's immediate family here.
  19. Leave This Blank:

  20. This field is not part of the form submission.