911 Address Request Form

Please Return to 407 Main Street South, Room 307 Towner, ND 58788 Or Email to [email protected]

Date ______

Owner or Resident:

Name: ______

Current Mailing Address: ______

City ______State______Zip Code______

Telephone Number______

Building Location: (Please include a sketch if possible)

Township Name, Section and Quarter : ______

Parcel ID: ______

Road that permanent driveway will branch off of______(ex:73rd ST N)

Avenue or Street that driveway will be parallel with______(ex: 1st Ave N)

Distance and direction from parallel road to driveway______(ex: 300ft East of 1st Ave N)

Closest Neighbor______

Closest Neighbor’s Address______

Are there any current structures on the property? yes no

If yes, What are the structure(s)?______

If no, what will be built? ______

When will it be built?______

______Official Use Only______

New Address Assigned______

Date of Notification______