Case Number:	Harvest Number:
The owner and/or operator agrees to waive the right of formal proceedings according to Section 2.2-4020 and 2.2-4021 of the Code of Virginia and consent to informal proceedings in accordance with Section 10.1-1181.2-C of the Code of Virginia regarding the conduct of silviculture activities; issuance of Special Orders.
SECTION 1 – Harvest Operator
Harvest Operator Name (Print)	Harvest Operator Signature	Date
SECTION 2 – Timber Owner
Timber Owner Name (Print)	Timber Owner Signature	Date
SECTION 3 – Landowner
Landowner Name (Print)	Landowner Signature	Date
SECTION 4 – Conference Officer
Conference Officer Name (Print)	Conference Officer Signature	Date