MDT Use Only Permit #: ______________ ☐ Approved ☐ Denied Date: _________________
OAC Agent
OAC Supervisor

Date:

Attn:	MDT – Outdoor Advertising Control

Permit # (s):

I am submitting this Permit Transfer Request for the above reference permit. I have received the required signed acknowledgements from both the current sign owner and the current landowner. The following information is provided for approval.

APPLICANT

First Name:
Last Name:

Address:	City, ST, Zip
Seasonal Address:	City, ST, Zip

Email:	Phone:

COMPANY INFORMATION (If applicable)

Company Name:

Address:	City, ST, Zip
Seasonal Address:	City, ST, Zip

Email:	Phone:

I understand that if a permit transfer is made when the permit is in violation of section 75-15-101 et seq., MCA, or section 18.6.202 et seq., ARM, or if a revocation proceeding is pending, I receive the permit(s) subject to revocation. MDT’s approval of a

By my signature/typewritten name, I declare under penalty of perjury and the laws of the State of Montana that the foregoing is true and correct and contains no willful falsifications of misrepresentations.

Signature	Date	Place of Signature (City, State)

LANDOWNER INFORMATION

Date:

Attn:	MDT – Outdoor Advertising Control

Permit # (s):

Applicant’s Name:

As requested by the above applicant, I am providing the following information as the current sign/permit owner for the purpose of transferring the subject permit.

LANDOWNER

First Name:
Last Name:

Address:	City, ST, Zip
Seasonal Address:	City, ST, Zip

Email:	Phone:

I acknowledge that I am the person in lawful control of the site location on which the sign is located.

By my signature/typewritten name, I declare under penalty of perjury and the laws of the State of Montana that the foregoing is true and correct and contains no willful falsifications of misrepresentations.

Signature	Date	Place of Signature (City, State)

SELLER/SIGN OWNER INFORMATION

Date:

Attn:	MDT – Outdoor Advertising Control

Permit # (s):

Applicant’s Name:

As requested by the above applicant, I am providing the following information as the current landowner for the purposes of transferring the subject permit.

SELLER/SIGN OWNER

First Name:
Last Name:

Address:	City, ST, Zip
Seasonal Address:	City, ST, Zip

Email:	Phone:

By my signature/typewritten name, I declare under penalty of perjury and the laws of the State of Montana that the foregoing is true and correct and contains no willful falsifications of misrepresentations.

Signature	Date	Place of Signature (City, State)