911 Address Request Form

Revised 8/17/2016

PhysicalAdress911Request.doc

Applicant will complete the top section of the form the best you can and supply this form to

the 911 Coordinator or proper County official. The County official will than complete the

bottom section of the form with the correct 911 address of the location described and

forward the form to WRT. Please include a map with road access and structure indicated.

You can print off maps from: Google, Google earth, Plat Books, etc.

To be completed by the Applicant

Date of Application: __________________ Applicant Name:___________________________________________

Mailing Address: __________________________________ City ______ State: _ __ Zip

Email Address: _____________________________ Best Contact Number: ________________________________

Name of Property Owner if different then applicant: __________________________________________________

Township: ______ Range: ________ Section: _______ Quarter Section: (circle one) NE, NW, SE, SW

Location of the structure in Decimal Degrees Latitude: ____________________ Longitude: _________________

Block Number: _____________ Lot Number: ______________ Addition Name: ____________________________

Road Name providing property access: ____________________________ Distance from Road: ____________ feet

Structure will be located off the above-named road: (circle one) NORTH, SOUTH, EAST or WEST

Dwelling Type (circle one)

Single Family Home RV or Camper Trailer Mobile Home Business

Industrial Site Construction Site Oil Well Site Other: ___________________

Signature: ____________________________________________________________________________________

To be completed by the 911 Coordinator or authorized County Official

Date Received: _____________________________

House #: ______________ Street Name: ________________________________________ Unit # _____________

City: _________________________________________Community: _____________________________________

County: _____________________________ Additional Address Information: ______________________________

Signature of person assigning 911 Address_____________________________ _____________________________

Coordinator or authorized County Official, please return this form and map via one of the

following; by USPS: at West River Telecom, Attn: Engineering, PO Box 467, Hazen, ND 58545,

by Fax: 701-748-7100 or by E-mailing: engineering @wrtc.com