Emily 911 Farm Entrance Program Application

Policy 79-2019 – Appendix 1

Emily 911 Farm Entrance Program Application

Applicant Details

Name(s):

Address:

City/Town:

Postal code:

Phone:

Email:

Farm 911 Location Details

Roll #:

Former township:

Road name:

Lot #:

Con. #:

Side of road:

Part #:

Plan #:

Specifically: metres

North

South

East

West

of:

(closest civic address)

Payment in the amount of $75.00 (refundable should the application be denied) shall accompany this application.

I/We hereby make application for an Emily 911 Farm Entrance Access Number at the location indicated above, and have read and understand the Acknowledgement.

Acknowledgement - North Dundas – Emily 911 Farm Entrance Program

I/We the undersigned owners of the property subject to the application, acknowledge that approval of an Emily 911 Farm Entrance Program application:

Is to assist in emergency situations only;
Does not permit further use or development of the property without the appropriate approvals;
Does not constitute the approval of an entrance nor does it deem the access safe for use or that it meets any municipal entrance standards;
Does not guarantee that access is adequate for emergency vehicles and where access is not adequate, emergency vehicles may not be able to enter the property; and
Requires the land owner to ensure the signage remains visible and is maintained. Should the signage be damaged, knocked down or removed the land owner shall contact the Municipality for replacement or repair of the signage.

Signature:

Sign above

Date:

For Office Use Only

Fee paid: $

received by:

on:

911 number assigned:

Staff comments:

Staff signature:

Date:

Witness	Applicant/Owner	Signature
Witness name:	Applicant/Owner	Signature: Sign above
Witness name:	Applicant/Owner	Signature: Sign above
Witness name:	Applicant/Owner	Signature: Sign above
Witness name:	Applicant/Owner	Signature: Sign above

[to be signed by all owners of the subject property]

Upon submission of your completed form, please call the Township of North Dundas at 613-774-2105 to process payment, or visit us in person at 636 St. Lawrence Street, Winchester, Ontario K0C 2K0.

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Policy 79-2019 – Appendix 1