MDT Use Only Permit #: ______________ ☐ Approved ☐ Denied Date: _________________
OAC Agent
OAC Supervisor
Under Mont. Admin. R. 18.6.211(10), permits may be

relinquished at the written request of either the permit

holder(s) or the landowner(s) and must be signed by the

current permit holder(s) subject approval by the Montana

Department of Transportation (MDT).

PERMIT HOLDER

First Name:
Last Name:
Business Name:
Address:	City, ST, Zip
Email:	Phone:	Permit #:

Permit number(s) to be relinquished:

I hereby certify that it is my intent to relinquish the above referenced permit(s). I recognize that the permit plates associated with each permit remain the property of MDT and the permit holders are obligated to return each permit plate to MDT following relinquish. I also understand the permit holders are obligated to remove the sign structure following relinquishment.

I also certify that I am authorized to seek relinquishment and sign this request on behalf of:

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)