USDA-Forest Service


(Ref.: FSM 27112, 36 CFR 251.54)


Applicant should request a meeting with the Forest Service representative responsible for processing the application, prior to completing this form. This meeting will allow a discussion of the form's requirements and identify those items to be omitted.

PART I - APPLICATION (Applicant Completes)

  1. Applicant naame and address
  2. Authorized Agent Name, Title and Address if different from item 1.
  3. Area Code and Telephone Number
  1. Applicant's
  2. Authorized Agent's
  1. As applicant are you?
  1. Individual
  2. Corporation
  3. Partnership/Association*
  4. State Government/State Agency
  5. Local Government
  6. Federal Agency

* If marked"x", complete PART II

  1. Specify what application is for: (Mark one box with "x")
  1. New authorization*
  2. Renew existing authorization
  3. Amend existing authorization
  4. Other*

*If marked "x", provide details under item 7.

6. If you are an individual or partnership, are you also a citizen of the United States? Yes No

  1. Describe in detail the land use, including: (a ) type of use, activity, or facility; (b) related structures and facilities; (c) physical specifications (length, width, acres, etc.); (d) term of years needed; (e) time of year of use or operation; (f) duration aand timing of construction; (g) temporary work areas needed for constructin; and (h) anticipated need for future expansion. (If extra space is needed, use page 3, REMARKS).
  2. Attach map covering area aand show location of poroposed use and/or furnish legal description of the land.
  3. Give statement of your technical and financial capability to construct, operate, and terminate the use for which authorization is requested, including the protection and restoration of Federal lands. (If extra space is needed, use page 3, REMARKS).