Request for Flood Information

2. Name of Applicant*

4. Applicant's Address*

6. Applicant's City*

7. Applicant's State*

8. Applicant's Zip Code*

10. Applicant's Phone Number*

    555-555-5555

11. Applicant's Email Address*

13. Applicant's Agent

14. Firm Represented

16. Firm's Address

18. Firm's City

19. Firm's State

20. Firm's Zip Code

22. Location of Property*

24. Legal Description of Property

25. Propert Identification Number (PIN)

27. Description of Property*
    -- Select One --Single FamilyMulti FamilyBusiness/Commercial Manufacturing

    Pick one

29. Applicant Signature*

    By typing my name I am electronically signing this application.

33. Is there an existing LOMA or LOMR?*
    -- Select One --YesNo

34. Is the main building within a Special Flood Hazard Area?*
    -- Select One --YesNo

35. Superseded?*
    -- Select One --YesNo

37. Flood Zone Designation*

38. Base Flood Elevation (in feet)*

40. Effective Date of Map: July 16, 2008

41. Community and Panel #*

43. Enclosed Information

44. Information provided by:*

46. Information provided on:*

    Date

Leave This Blank:


47. 1. Receive email copy
48. Email address

    This field is not part of the form submission.

49. Submit

* indicates a required field