First Name:
Last Name:
E-Mail Address:
Telephone Number:
Vehicle Year:
Vehicle Make:
Vehicle Model:
Zip Code:
Event Date & Location:
-- Select --
November 14th: 16125 Wolf Rd, Orland Park, IL 60462, 9am-12pm
November 7th: 2201 Autobarn Place, Evanston, IL 60202, 9am-12pm
Where did you receive a card to register for an upcoming Lightsaver event?
-- Select --
Flier distributed thru community partners
Flier distributed thru Sheriff's social media
Stand in courthouses
Card distributed by patrol officers
Card distributed by Community Engagement Unit
Bumper sticker on participating vehicles
Other / Did not receive
Please select how many of each light you need replaced below:
Headlight Bulb (quantity):
0
1
2
Taillight Bulb (quantity):
0
1
2
Front Turn Signal Bulb (quantity):
0
1
2
Rear Turn Signal Bulb (quantity):
0
1
2
License Plate Bulb (quantity):
0
1
2
Other Bulb (quantity):
0
1
2
Other Bulb Description:
How did you hear about this program?
-- Select --
Website
Social Media
Word of Mouth
Other
Other: