To apply for a 911 address for your new home or business, please fill out the e-form below.  Once completed, press the Submit Form button to send the request form to the 911 Coordinator.  If you prefer you can also download a printable version of this form and mail, fax or hand deliver it to the 911 Coordinator at the address listed above.  Click here for a Microsoft Word version of the form and click here for an Adobe Acrobat PDF version.. Within five (5) working days after you submit your form, you will receive notice of your assigned address by telephone.  A follow-up confirmation letter will be mailed to you at the current mailing address you provided on this form. If you make a mistake before you send your address request information, press the Rest Form button to clear the form and start again. IMPORTANT NOTES: A 911 address for a new structure should be obtained before making arrangements for utility services.  Utility companies (telephone, electric, gas, water, and so forth) will request a 911 address for structures to be served. An applicant requesting an address in Crawford County outside of a city must obtain a culvert permit from the Crawford County Road Department if the structure to be addressed is access off of a county maintained road.  Please call (479) 474-6017 for permit information.  A 911 address will not be provided an applicant until the 911 Coordinator has been notified that the applicant has obtained this permit.
Applicant Name:		Date:
Daytime Phone:		Evening Phone: :
Email Address:
Phone number to call to provide your assigned address:		Current mailing address:
Property owner (if different than above):		Property Location:	Select County Sebastian Crawford Franklin Scott
If an existing structure/mobile home, who was the previous owner or resident (if known):		If an existing structure/mobile home, about how old is the home/building?
Property’s access road/street name:		If property will share an existing driveway, address of shared driveway:
To help us locate and address your new structure, please provide the name(s) of your nearest neighbor(s) and address(es), if known: Neighbor’s Name 911 Address From this neighbor, your property is to the front, back or side. Select One Front Back Side Select One Front Back Side Select One Front Back Side Select One Front Back Side Select One Front Back Side Select One Front Back Side Select One Front Back Side Select One Front Back Side Structure Information:  Is the structure a: Select One Single Family House Apartment Duplex Mobile Home Business If apartment, number of units: If none of the above please specifi: Is the structure visible from the road? Select Yes/No Yes No     Is the Structure: Select One Fully Completed Under Construction Mobile Home       If under construction what are the color of the flags?     Are the flags visible from the road? Select Yes/No Yes No     If fully constructed describe the outside walls: Select Yes/No Wood Vinyl Rock Other     Is this a mobile home or manufactured home?     Outside wall color:   Please provide additional information that will help us locate the structure to be addressed.  Please be as descriptive as possible.  Include distance from the closest intersecting road/street and directions to the structure.