Tract Number:	Parcel:
Submitted By:	Date Submitted:
The Virginia NRCS Conservation Planning Activity (CPA 106) – Forest Management Plan is a customized, and site specific plan that contains recommended forest-related conservation treatment activities to address one or more resource concerns and meet your forestland objectives. The Design and Implementation Activity (DIA 165) – Forest Management Plan is a detailed plan that describes how to implement the site-specific forestry activities that are identified in the CPA 106 plan. The information on this form will help the forester develop a management plan that meets your objectives.
SECTION 1 – Applicant Information
Last Name:	First Name:
Mr.	Mrs.	Ms.
Mailing Address:
City:	State:	Zip:
Home Phone:	Work Phone:
E-mail:	Cell Phone:
SECTION 2 – Tract Information
County:	Tract Name:
Tract Location: (include tax map id)
Total Tract Acres:	Acres of Forested Land:
Is this tract your primary residence?	Yes	No	If no, how many days per year are spent on the tract?
Is this tract a Certified Tree Farm?	Yes	No	If No, would you like information about Tree Farm?	Yes	No
Are you the sole owner of the property?	Yes	No
If no, please list the other owners.
How long have you owned this forested land?	1 year	2-5 years	6-15 years	16 or more years
Have you ever harvested timber from this tract?	Yes	No
Do you own forestland in other Virginia counties?	Yes	No
If yes, please list counties and number of forested acres.
If you own other forested land, have you ever harvested timber from these tracts?	Yes	No
Have you ever received professional forestry advice about managing your forested lands?	Yes	No
If yes, from whom? (check all that apply)	Private Consulting Forester	Virginia Dept. of Forestry	Industrial Landowner Asst. Prog.
Other (please specify)
What did you receive professional forestry assistance for? (check all that apply)
Preparing a Forest Management Plan
Timber Sales or Harvesting (timber marking, sales assistance, timber valuation, etc.)
Forest Stand Management (thinning, prescribed burn, pruning, herbicide application, etc.)
Reforestation and Planting
Wildlife Management
Other (specify)
SECTION 3 – Landowner Objectives
Please rank the five most important objectives you want to consider in your Conservation Planning Activity – Forest Management Plan, where number 1 indicates the most important and number 5 is relatively less important.
Maintenance of a Scenic Forest	Wildlife Habitat
Wildlife for Hunting	Real Estate Investment
Managing Timber for Income (to sell timber)	Protect Rare, Unique Natural Areas
Forest Stand Management (maintain health of forest)	Historical / Cultural Resources
Non-Wildlife Related Outdoor Recreation (Hiking, Non-Motorized Trail Biking, Horseback Riding, etc.)	Soil and Water Conservation
Other (specify)
If you are interested in managing for wildlife, please rank the five most important species you are most interested in, where number 1 indicates most important and number 5 is relatively less important.
Deer / Turkey	Rabbits
Squirrel	Bobwhite Quail
Fish	Water Fowl
Songbirds	Fur Bearers (Fox, Raccoon)
Rare, Threatened or Endangered Species (Plants or Animals)	No Species Preference
Other (specify)
Is this property under a conservation easement?	Yes	No
If yes, who holds the easement?
If no, would you like information about conservation easements?	Yes	No
SECTION 4 – Landowner Agreement
I understand:
That I am encouraged to implement recommended practices as I am able, but I am not required to. That a Conservation Activity Plan and the Design and Implementation Activity plan must be prepared by an NRCS-certified technical service provider from the list located on the TechReg Technical Service Provider Registry site: http://techreg.usda.gov/index.aspx. That I can have a CPA 106 and a DIA 165 plan developed for my property at the same time, or only the CPA 106. A DIA 165 plan can be developed in the future if it is an extension to a previously written and approved CPA 106 plan, a Forest Stewardship Plan or a Tree Farm Plan.
I choose to have a:
CPA 106 Plan only developed for my property.
CPA 106 Plan and a DIA 165 Plan developed for my property.
DIA 165 Plan only developed for my property, and I have attached a copy of my approved forest management plan.
Landowner Name (Print)	Landowner Signature	Date
SECTION 5 – Conservation Planning Activity and/or Design and Implementation Plan to be Prepared By
Agency or Company (Print)	E-mail	Phone Number
Forester Name (Print)	Forester Signature	Date
Return completed application to the forester designated to prepare the Conservation Planning Activity and/or Design and implementation Activity plans.