SECTION 1 – Applicant Information
Applicant Name:
Agency/Organization:
Mailing Address:
City:	State:	Zip:
Phone:	Fax:
E-mail:
SECTION 2 – Proposed Burn Information
County of Proposed Burn:	Acres of Proposed Burn:
Purpose of Proposed Burn (be specific as to the target species and type of burn):
Certified Prescribed Burn Manager:	Name:	Cert. No..:
Applicant must attach a copy of the Burn Plan to include the Smoke Management Plan, Location Map and Tract Map. The Burn Plan must be specific for the area to be burned under this application. Applicant must also attach a statement completely explaining why the burn needs to be accomplished during the exemption period. This application will be reviewed and evaluated for approval. A copy of the processed application will be returned via US mail or fax. Applications must be received prior to February 1 for exemption consideration for this calendar year. If approved, this exemption is only good for the Agency/Organization identified on this application and is only valid through the last day of April following the date the exemption is approved. On the day of the prescribed burn, I agree to call the Regional Office of the Virginia Department of Forestry prior to the start of the burn. I agree to the conditions under which this application is approved and agree that no alteration will be made to the proposed plan once approved for exemption. I understand that I am responsible for the burn, liable to laws pertaining to escaped fires and all parts of §10.1-1105 of the Code of Virginia.
Applicant Name (Print)	Applicant Signature	Date
Attach a copy of the Burn Plan, including Smoke Management Plan and Location Map. Send application to: Virginia Department of Forestry, 900 Natural Resources Drive, Suite 800, Charlottesville, VA 22903 Attach a copy of the Burn Plan, Smoke Management Plan, Location Map, Tract Map and Reason for Exemption.
SECTION 3 – DOF Determination
Date Application Received:
Approved	Exemption No.:
Comments:
Denied	Comments:
Prescribed Burn Program Manager (Print)	Prescribed Burn Program Manager Signature	Date