Temporary Road Closure Application Form

Primary Contractor Details

Name:	Click here to enter name
Company:	Click here to enter company
Phone number:	Click here to enter phone no.
Mobile number:	Click here to enter mobile no.
Email:	Click here to enter email
Date of application:	Select date

Closure Details

Reason for closure:	Click here to enter event name or purpose of road/infrastructure works
Road or section of road to be closed: Eg: High Street from Percival Street to Victoria Street, Rangiora	Click here to enter road or section of road to be closed
Closure period: Eg: 9am, Monday 18 February 2020 to 5pm, Friday 28 February 2020, or Friday 28 February 2020 from 10am to 2pm	Click here to enter time and date

200129011153 Impacts to Areas of Interest

☐	Level 1 High Volume (L1HV) Roads	☐	Hospitals, medical centres or schools
☐	Bus Route	☐	Dense commercial spaces e.g. main roads through Kaiapoi and Rangiora
☐	Pegasus Town or Red Zone

Note:	Detour routes must be shown in the TMP on a separate diagram(s), with clear detail showing which roads are being used and what direction traffic is traveling.

Office Use Only Approved by:

Version 1.1 - April 2020 .