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By signing, the undersigned certifies that he /she has read and understood the submittal requirements <br />outlined, and that he /she understands that omission of any listed item may cause delay in processing the <br />application. I (We), the undersigned, acknowledge that the information supplied in this application is <br />complete and accurate to the best of my (our) knowledge. <br />PROPERTY OWNER OF TAX LOT: Z 3 0 3 <br />Name (print): �1�ucr 1 � 6vs �C)mle / <br />Address: 3 YV L,p;J Email: Wz t:: & MCAST, <br />City / State/ Zip: � - 6 ` <br />� EYv L—, Phone: Fax: <br />Signature: Date: <br />PROPERTY OWNER OF TAX LOT: <br />Name (print): <br />Address: Email: <br />City /State /Zip: Phone: Fax: <br />Signature: Date: <br />PROPERTY OWNER OF TAX LOT: <br />Name (print): <br />Address: Email: <br />City /State /Zip: Phone: Fax: <br />Signature: Date: <br />SURVEYOR: <br />Name (print): <br />Company /Organization: <br />Address: - P �, - rX �5� e� -! 7 -7 S <br />Annexation Last Revised May, 2009 Page 3 of 4 <br />Application Form <br />