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

SIGN OWNER/APPLICANT

First Name:
Last Name:

Business Name:

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

Email:	Phone:

Permit #(s):

Tag replacement fee is $20 payable to:

Montana Department of Transportation

Outdoor Advertising Control

2701 Prospect Avenue

PO Box 201001

Helena, MT 59620-1001

If you would like to pay this invoice with a credit card or e-check, please log into your sign owner dashboard and click on the Payment Due button. For questions, contact OAC support at mdtoacctrl@mt.gov or call (406) 444-7232.

Note: The statement below must be executed by the owner or other authorized representative of the business, corporation or individual holding the permit.

I hereby certify that the above-referenced permit tag has been lost, stolen or destroyed, and a replacement is required. I further certify that I am authorized to sign this statement on behalf of:

Name of business, corporation or individual holding permit:

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)