MDT Use Only Permit #: ______________ ☐ Approved ☐ Denied Date: _________________
OAC Agent
OAC Supervisor
SIGN OWNER/APPLICANT

First Name:
Last Name:

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

Email:	Phone:

EXISTING LOCATION

Highway #:	Side of Hwy:	☐ North	☐ South	☐ East	☐ West

City/Town:	County:

Nearest Mile Marker or Address of Sign Location:

DESCRIPTION OF SIGN STRUCTURE

Style:	☐ Single Face	☐ Double Face	☐ Wall Mount	☐ Side by Side	☐ V-Shaped
☐ Stacked	Will stacked be Double Face:	☐ Yes	☐ No
☐ Electronic Billboard	☐ Yes	☐ No

Sign Post	☐ Steel	☐ Wood	☐ Monopole	☐ Lighted	☐ Yes	☐ No
☐ Other

DIMENSIONS

Insert sign width (W), height (H) including border & trim, and distance (D) between signs for a Side by Side or Stacked structure.

Sign Width (W)
Sign Height (H) including border & trim
Distance between sign for Side by Side or Stacked Structure
Total Height of sign structure
HAGL: Height of bottom of sign to ground level – measured at right angle, road surface to sign
Sign face square footage

Encroachment: If a “Welcome To” sign is located anywhere within the Right-of-Way of a highway controlled by the Montana Dept. of Transportation (MDT), an encroachment permit must also be obtained from MDT Maintenance Division prior to the sign application being processed or approved.

SIGN OWNER/APPLICANT CERTIFICATION

I agree to abide by the provisions on the reverse side of this application and 75-15-101, et seq., Montana Code Annotated, and 18.6.202, et seq., Administrative Rules of Montana. Upon approval, failure to stay in compliance with all local sign regulations may result in revocation of this sign permit. Providing incorrect or false information whether unintentional or not may result in permit revocation. For sign relocations: upon approval of the new location, the former location becomes revoked. The permit will be transferred to the new location.

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)

SIGN OWNER/APPLICANT – LANDOWNER AFFIDAVIT

(or if applicable, attach copy of easement allowing sign)

I,	(print name – Sign Owner/Applicant

AND

I,	(print name – Landowner

by our signature do swear that the information given herein is true to the best of our knowledge and belief that we will comply with Montana Codes Annotated 75-15-101 through 75-15-134 and the Administrative Rules of Montana (ARM) 18.6.202 through 18.6.272 covering the granting, renewal, and revocation of permits for Outdoor Advertising and that the Agent for the applicant attests that they have the authority to contract in this matter and that the landowner does hereby acknowledge that the applicant has my consent to erect and maintain said advertising sign on my property and that both applicant, landowner, and their assigns herein grant to the Montana Department of Transportation (MDT) the right to enter the property in question for the purpose of inspecting said sign or remove any illegal sign. (MCA 75-15-131)

We also agree to hold MDT harmless and indemnify the Department for any damage caused either directly or indirectly by the erection and maintenance of said structure. In lieu of the landowner's acknowledgment, attach a lease or dated statement signed by the landowner (identify sign location by state route, County, side of roadway, and distance to milepost). Should the landowner be represented by an agent in this matter, documentation of said agent's authority which is satisfactory to the Department is required. A dated statement of lease must include a right of entry in favor of and acceptable to the Department for the purpose of inspecting said sign site or to remove any illegal sign.

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)
Sign Owner/Applicant Signature

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 Signature

Landowner Address?
City, ST, Zip

Email:	Phone:

SIGNATURES REQUIRED BY BOTH SIGN OWNER/APPLICANT & LANDOWNER