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Civic 911 Address Request Form
Municipality:
Former Township Name:
Roll Number:
Is this a severance from the above parcel, with NO roll number at this time?
Is this a severance from the above parcel, with NO roll number at this time?
Yes
No
Owner Name:
Entrance on Road Name:
Legal Description (Lot/Con and/or Plan/Part Number):
Existing Civic Address:
Existing Landline Phone Number:
Is this the only application for this property?
Is this the only application for this property?
Yes
No
Is this a change in address?
Is this a change in address?
Yes
No
If yes, effective date:
Is this an additional address?
Is this an additional address?
Yes
No
If yes, reason:
Please provide a clear sketch displaying the subject property, location of entrance and the road name.
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Provide the distance in meters from the centerline of the entrance to the nearest intersection (include road names):
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