Address request from
Needing a new address? Complete the following form and submit. Its that simple.
Today's Date
-- dd/mm/yy
Please provide the following contact information: This information is strictly confidential and is used solely for assigning your new address and adding you and your address to the 911 database
First Name Last Name Work Phone Home Phone FAX E-mail
Please supply us with a contact number. This will enable us to contact you when your new address has been assigned.
County of new address
Blank Overton Pickett
Prefix Directional.
Blank N S E W
Street Name of New Address.
Street Suffix
Blank ST LN HWY RD LP CT AVE CIR SQ EST
Post Directional.
Address Request Type.
New Home New Single Wide Mobile Home New Double Wide Mobile Home New Business Existing Single Wide Mobile Home Existing Double Wide Mobile Home Existing Home Existing Business Existing Other Subdivision Lot Telephone Substation Duplex Oil Well Barn Grain Bin Gas/Oil Pumping Station New Other
Color of New Structure.
Blank White Blue Red Green Almond Tan Orange Cream Violet Off White Beige Yellow Other
New Structure: Driveways need to be marked with RED or ORANGE stakes, flags, etc... Plain Sticks, Branches, Tobacco Sticks, etc will not be visible and are not acceptable. If driveway markers can not be found there will be a delay in obtaining the address. It is preferable that the owner mark the location of new structures with same type stake for GPS of the new address. Is the driveway marked?
Driveway Marked?
Neighbors Name/Address (nearest to new address)
Directions to new address. Give detailed directions. (example. Byrdstown Hwy left onto Willow Grove Hwy. one half mile on left next to church)