SECTION 1 – Current Landowner Information
Landowner Name:
Mailing Address:
City:	State:	Zip:
Phone:	Fax:
E-mail:
SECTION 2 – Property Information
Property must meet the following conditions to be eligible: (check all that apply)
Property owned by the same family for at least 100 consecutive years	Years of Family Ownership:
Property includes at least 20 contiguous acres of managed forest	Total Acres:
Forested Acres:
Property is lived on, or actively managed by, a descendant of the original owners
Name of Descendant Residing On or Managing the Property:
Relationship to Landowner:
Property has a history of timber harvests or forest management activities
Describe the history of timber harvests or forest management activities: (attach additional sheets if desired) Attach supporting documentation of recent activities (examples: Forest Stewardship Management Plan; statement from a VDOF forester or a consulting forester, and/or timber harvest contracts)
County/City Property is in:	Tax Map Parcel Number:
Location of Property/Tract:
Legal Description/Plat Reference: (attach map)
SECTION 3 – Previous Landowner History
Property must be owned by the same family for at least 100 consecutive years to be eligible. Starting with the current landowner, list the chain of ownership back a minimum of 100 years from the year of application.
Name as it Appears on Deed	Family Relation to Previous Landowner	Years of Ownership	Deed Reference
- Present
-
-
-
-
-
-

SECTION 4 – Recognition Information
Last Name or Family Name to Appear on Certificate:	Family
One Sign is Provided, Additional Signs May be Purchased:	Number of Additional Signs to Purchase:
SECTION 5 – Applicant Agreement
I certify that the information provided on this application is complete and accurate. I understand that the Virginia Century Forest Program is strictly a recognition program. While there are no tax incentives or additional legal protections for being a part of the program, you can be proud of your family’s conservation heritage when you display your certificate and sign. All submissions become property of Virginia Department of Forestry (VDOF). I grant the Virginia Department of Forestry permission to use any material submitted in or with this application for promotional and/or educational purposes. I understand that recognition of a property as a Century Forest is a symbolic act that does not create or result in additional obligations on the part of the property owners, such as opening their land to the public or granting agency representatives special access rights.
Applicant Name (Print)	Applicant Signature	Date
SECTION 6 – Acknowledgement (to be completed by a Notary Public)
Commonwealth of Virginia	County/City of:
The foregoing instrument was acknowledged before me this
by	.
Date	Name of Person Acknowledged
Notary Public Name (Print)	Notary Public Signature	My Commission Expires
SECTION 7 – Submission Instructions
Attach supporting documentation: Proof of Ownership (Source Deed); Proof of Timber Harvests or Forest Management Activities (examples: Forest Stewardship Management Plan; statement from a VDOF forester or a consulting forester, and/or timber harvest contracts); Hardcopy Map of Tract. Send completed application package to the VDOF Headquarters Office for certification, and Attach any additional information or history about the property to support the application. Copies of historical information, including photos are encouraged but not required. (All information, including photos, will be retained by the VDOF for future reference.) Submit Application and Supporting Documentation to: Virginia Department of Forestry Century Forest Program 900 Natural Resources Drive, Suite 800 Charlottesville, VA 22903 Questions may be directed to conservation@dof.virginia.gov .
SECTION 8 – VDOF Approval
Based on the information provided, I certify that this property qualifies for recognition in the Century Forest Program.
Century Forest Program Manager Name (Print)	Century Forest Program Manager Signature	Date
I approve the applicant for recognition in the Century Forest Program.
State Forester or Designee Name (Print)	State Forester or Designee Signature	Date