Civic 911 Address Request Form

Required fields are marked with asterisks (*)

Municipality:

Former Township Name:

Roll Number:

Is this a severance from the above parcel, with NO roll number at this time?

Yes

Owner Name:

Entrance on Road Name:

Legal Description (Lot/Con and/or Plan/Part Number):

Existing Civic Address:

Phone Number:

Email Address:

Existing Landline Phone Number:

Is this the only application for this property?

Yes

Is this a change in address?

Yes

If yes, effective date:

Is this an additional address?

Yes

If yes, reason:

Please provide a clear sketch displaying the subject property, location of entrance and the road name.

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Provide the distance in meters from the centerline of the entrance to the nearest intersection (include road names):