Roadside memorial sign application form

Submit the following items along with this completed form:

Written consent from immediate family member of victim
Copy of the Washington State Patrol’s Collision Report or a Collision Report Number

For renewal applications, previously submitted documentation may not be required unless information has changed. Additional documentation may be requested if records cannot be verified.

Please complete separate applications per individual.

Application type

New application

Renewal

Upload written consent from immediate family member of victim (if not immediate family member) and/or copy of Washington State Patrol’s Collision Report

One file only.
100 MB limit.
Allowed types:

gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip

Section I: Applicant information

Applicant name

Applicant email

Applicant phone number

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Relationship to deceased

Section II: Collision information

Name of deceased

Date of collision

WSP Report Number

State highway of collision

Approximate milepost, GPS coordinates or approximate address

Nearest cross streets

County

Nearest city/town

Section IV: Renewal information

Are you the original applicant?

Yes

If not original applicant, explain your relationship to the deceased:

Renew sign with no changes?

Yes

What do you want to update?

Update safety message

Update supplemental sign message

Update sign with this message:

Instructions to applicant

In order to be considered for a new sign, the collision must have occurred on a Washington State Highway and have occurred within six years of the application date.

Complete this application and submit it to the Washington State Department of Transportation. Include written consent from immediate family member (if not an immediate family member), attach either a copy of the Washington State Patrol’s collision report or collision report number.

Section I

Fill in your name, e-mail, phone number, address and relationship to the deceased.

Section II

List the full name of the deceased, date of the collision, Washington State Patrol collision report number, Washington State Highway location of the collision, 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 approved list of safety messages to place above the supplemental name plaque. Then write the deceased person’s name as you would like it to appear on the name plaque. This is how it will be printed on the sign and is subject to approval by the Department.

Section IV

Complete section IV only if renewing a sign; indicate if you are the original applicant, if not, please explain your relationship to the deceased. Please indicate if you would like no changes to the signs or want to update either the safety message or the supplemental sign.

How to submit by mail or email

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.

Submit to:
Washington State Department of Transportation
Roadside Memorial Program
PO Box 47344
Olympia, WA 98504-7344

Roadside memorial sign application form

Instructions to applicant

Section I

Section II

Section III

Section IV

How to submit by mail or email

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