Address Request Form

Applicant Info

Applicant Name *

The first and last name of the person who is requesting an address

Applicant Current Mailing Address *

Enter your address, City, ST, and Zip

Applicant Phone *

Enter your primary phone number including the area code so we may call if more information is needed.

Applicant Email

Please provide an email address we may use for additional information

Alternate Phone

Enter another phone number we may use

Do you have a Contractor? *

YES - Enter the contractor's name and phone number below

Do you have a Contractor? YES - Enter the contractor's name and phone number below

Structure Info

New Address is On *

Enter the Street or Road Name that this new address will be on

Community *

Select the Post Office that delivers mail to this location

Parcel Identification Number

Enter the Parcel ID if available

Type of Structure to be Addressed *

Type of Structure to be Addressed Other - Describe below

Structure Description *

Help us find your structure by providing a good description

Addresses Structure is Between *

Enter the two address numbers your structure will be between. For example 1245 - 1351

Structure Visible from Road? *

YES

Is the structure readily seen from the road?

Shared Driveway? *

YES - Enter the existing structure's address

Shared Driveway? YES - Enter the existing structure's address

Will your structure share a driveway with another structure?

Comments

Enter any additional information that will help us process your request.

Pike County 9-1-1 staff strives to have an address assigned within ten business days from receiving the request. However due to several factors such as address discrepancies, private drive naming, or staffing levels, that goal is not always met. *

I have Read and Understand the Above

Dial 9-1-1 for Emergencies!

Address Request Form