Exit Pickup Optimization Request Form Question Title 1. Company Name* Question Title 2. Submitter Name* Question Title 3. Submitter Email* Question Title 4. Submitter Phone* Question Title 5. Business Address* Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Question Title 6. Are you requesting for one designated pickup or multiple? One Two or more Question Title 7. Provide brief description of the issue you are having with your office location.* Question Title 8. If the issue is not related to a driver arriving at the right location/pin of your address, please describe the issue here. * Question Title How To: accurately find the lat & long of the address, type in the address in Google Maps > right click the red pin > click on the lat & long numbers to copy > paste below Question Title 9. Enter the latitude and longitude of your preferred entrance/pick up point.* Question Title 10. Upload the smart pickup boundary for the pick up location* Draw the boundary of the pickup on a map/print out of the area and upload the picture. This can be done in Google maps via a screenshot. Indicate if border roads or parking lots that should be included. This is the region within which pick ups will occur. PDF, PNG, JPG, JPEG file types only. Choose File Choose File No file chosen Remove File Draw the boundary of the pickup on a map/print out of the area and upload the picture. This can be done in Google maps via a screenshot. Indicate if border roads or parking lots that should be included. This is the region within which pick ups will occur. Question Title Example image of map showing where old (wrong) pickups were going and star indicates where the (correct) pickup should be Question Title 11. Desired name of pick up location. This is what you will see in the Uber Health Dashboard.* 100% of survey complete. Done
