Tract Number:
SECTION 1 – Landowner Information
Last Name:	First Name:
Mailing Address:
City:	State:	Zip:
Home Phone:	Work Phone:
E-mail:	Cell Phone:
SECTION 2 – Plaque Information	(a * will be placed on a Virginia map indicating the location of the Stewardship Forest based on the county)

Landowner Name(s)	County Name
C	O	U	N	T	Y
Tract Name (optional)	Date (month and year)

SECTION 3 – Property Information
Land Use Information – Summarize the current land for this property by acreage:	Management Objectives – Indicate the most significant Resource Management Objectives of the landowner by placing a “1” and a “2” in two of the blocks to indicate Primary and Secondary objectives:
Current Land Use	Acres
Forest
Agriculture	Wildlife
Wetlands, Rivers, Ponds, Lakes	Recreation and Environmental
(Specify)	Soil and Water
Other	Forest Products
Total
Is there a written resource management plan for this property that covers the next ten years of practices?	Yes	No
Do the plans cover the management objectives of the landowner?	Yes	No
If no, what objectives are not covered in the management plans?
List the government agencies or private resource professionals assisting the landowner in managing the properties.

SECTION 4 – Property Management
List by forest type and general age class, accomplishments during the last ten years, which helped the landowner achieve the primary and secondary resource management objectives.
Forest Type, Wildlife Species or Recreational Facilities, etc.	Quantity	Units (acres, feet, etc.)	Year	Accomplishment
List other accomplishments:
SECTION 5 – Nominating Forester	VDOF Forester	Consultant Forester	Industry Forester
Nominating Forester Name (Print)	Nominating Forester Company
Nominating Forester Signature	Date	Phone Number
SECTION 6 – Inspection
I hereby certify that the above information is accurate to the best of my knowledge and I recommend certifying this property as a Stewardship Forest.
Deputy Regional Forester Name (Print)	Deputy Regional Forester Signature	Date
Wildlife Biologist Name (Print) (if applicable)	Wildlife Biologist Signature	Date
Other Resource Specialist Name (Print) (if applicable)	Other Resource Specialist Signature	Date