FS-2700-10 Technical Data for Communications Uses

	USDA Forest Service FS-2700-10 (05/09) OMB No. 0596-0082
	USDA Forest Service Technical Data Communication Type Land Use (Ref. FSM 2700)		INSTRUCTIONS: Applicant completes system items 1 to 16, and submit this form, license(s), along with an application to place communication equipment on National Forest System land. This form is authorized by Federal Land Policy and Management Act of 1976, P. L. 94-579 to evaluate the requested use and no authorization may be issued unless this form is completed.
	1. Applicants's Name:       Street Address:       City State & Zip Ccde:       Telephone Number: (   )     -      2. Location Applied For: Site Name:       Forest:       District:       3. Technical Data:
		a. License number and call sign		     
		b. Date license issued		      (mm/dd/yyyy)
		c. FCC/NTIA eligibility		     
		d. Class of service (FCC/NTIA symbol)		     
		e. Type of emission (FCC/NTIA symbol)		     
		f. Transmit output power (watts)		     
		g. Transmit output (Effective Radiated Power)		     
		h. CTCSS control tone (Hz)		     
		i. Receive frequency crystal		     
		j. Receiver IF frequency 1		     
		frequency 2		     
		k. Receive frequency		     
		l. Transmit frequency crystal		     
		Multi 1		     
		Multi 2		     
		Multi 3		     
		Multi 4		     
		Output		     
	4. Control Method: Wireline Radio Link Local Repeater Microwave Other 5. Control Frequency       6. Antenna Type: Omnidirectional Directional Polarization Gain       dB Height to top of antenna from ground level       ft.; Dish Diameter       ft. Beam path with      deg.; Azimuth      deg.; Tilt       +/- deg.; Name of place beam goes to:       Beam path length      ft. 7. Tower Type: Pole – Guyed Self-Supporting Height      ft. Metal – Guyed Self-Supporting Height      ft. 8. Ground elevation above sea level at the base of the tower      ft. 9. Tower: Latitude:       Longitude       10. Chief Engineer or Service company:       Street Address:       City       State       Zip Code       Phone Number (   )     -      Emergency Number (   )     -     
11. Will station have commercial power? Yes No 12. Will station have standby power plant? Yes No 13. Will station have commercial telephone? Yes No Area code and Phone number (   )     -      14. Attached (check appropriate block(s)) : Current FCC License/NTIA Radio Frequency Authorization FCC License Application FCC Construction Permit with Land Owner (FS) sign-off 15. Additional Information: NOTICE: Title 18, U.S.C. Section 1001, makes it a crime for any person to knowingly and willfully make any false, fictitious, or fraudulent statements or representations to matters under the jurisdiction of the United States Government. 1 6. Applicant's Signature: Title:       Date:       (m/dd/yyyy)
BURDEN AND NONDISCRIMINATION STATEMENTS According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0082. The time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer. The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 552) govern the confidentiality to be provided for information received by the Forest Service.

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