Instructions to applicant
In order to be considered, the collision must have occurred on a Washington State Highway and have occurred within six years of the application date. This application must be completed and submitted to the Washington State Department of Transportation along with written consent from immediate family member (if not an in immediate family member), a copy of the Washington State Patrol’s Collision Report. If the collision report is not available, a report number is sufficient.
Section I
Fill in your name, address, daytime phone number, and e-mail address.
Section II
List the full name of the deceased, date the collision occurred, Washington State Patrol collision report number, Washington State Highway on which the collision occurred, other location details such as approximate milepost, GPS coordinates, or approximate address, nearest intersection, county, and nearest
city or town.
Section III
Choose from the following list of safety messages which will be placed above the supplemental name plaque. Then write the name of the deceased how you would like it to be seen on the name plaque. This will be how it is printed on the sign and is subject to approval by the Department.
Section IV
Submit the completed form and all supporting documentation to the Washington State Department of Transportation by mail to the address shown below or by email to roadside.memorial@wsdot.wa.gov.
You can also submit in writing to:
Washington State Department of Transportation
Roadside Memorial Program
PO Box 37344
Olympia, WA 98504-7344
