Request for 911 Address Assignment

2. Contact Information
4. Name
5. Business Name (If Applicable)
7. Email Address
8. Phone Number
10. Current Mailing Address
12. City
13. State
14. Zip Code
16. Property Type
17. What is the purpose of the address?
19. Select Property Type*

    Select the type of property for the 911 address request.

    1. Agricultural
    2. Residential - Single Family
    3. Residential - Multi-Family
    4. Commercial
    5. Industrial
    6. Out of City Limits
20. Please select from the options below:*

    1. New Construction - Residential/Agricultural - Single Family
    2. New Construction - Residential - Multi-Family
    3. New Construction - Commercial/Industrial
    4. Accessory Building - Residential/Agricultural
    5. Accessory Building - Commercial
    6. Accessory Building - Industrial
    7. Utility service only (i.e. additional water meter, electric service, etc.)
22. What is the location of the property needing an address?
    One of the below is required in order to assign an address. If you are unable to provide this information please contact Clayton Sedberry - 479-756-7708 or Aaron Hudman - 479-750-8550

    One of the below is required in order to assign an address. If you are unable to provide this information please contact Clayton Sedberry - 479-756-7708 or Aaron Hudman - 479-750-8550
24. ANY OF THE BELOW ITEMS MAY BE USED TO REQUEST A NEW 911 ADDRESS.
26. Parcel ID Number
27. Existing Physical Address
    Only if requesting additional address.
29. Subdivision Name, Block, Lot Number
30. Other Document

    1. Warranty Deed
    2. Survey/Drawing/Map
    3. Legal Description
    4. AutoCAD File
32. Upload Document
    Uploaded documents should be in an image file format (.pdf, .jpeg), AutoCad .dwg/.dxf or in a Microsoft Word compatible format.
34. Additional Information
    Use the space above for any additional information that would aid in the assigning a new 911 address.
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field