SECTION 1 – Permission
Date:
To:	Commonwealth of Virginia, Department of Forestry
We,	, hereby grant
Agency
permission to the Department of Forestry to operate	mobile(s) and	portable radio(s)
Quantity	Quantity
using the call sign(s) and frequency(ies) listed below for coordinating forest fire detection and control in
County/City, Virginia.
County or City Name
FCC Call Sign	Channel	Transmit Frequency	Transit Subaudible Tone (if needed)	Receive Frequency	Receive Subaudible Tone (if needed)	Used For
SECTION 2 – FCC License Contact
Contact Person:
E-mail:	Daytime Phone:
SECTION 3 – Authorization
Authorized Representative Name (Print)	Authorized Representative Title
Authorized Representative Signature	Date