Woodsy Owl Licence Amendment/Renewal

US Forest Service (v05-2014)

OMB 0596-0087 Exp. 06/30/2014

Woodsy Owl^®

License

☐Amendment

☐Renewal (please check appropriate box)

Woodsy Owl License
Company Name	     
Contact Name	     
Address	     
City, State, Zip	     
Telephone number	     
Facsimile	     
E-mail	     
Additional Products added to license	     
Additional Products added to license	     
Royalty Percentage	     
Effective Dates of License	Same term as base license, unless change is requested below.
From	     
To	     

All terms and conditions of the original License and any Amendments shall continue in full force and effect.

Signature Date	Signature Date
US Forest Service Representative Name:       Title:      	Licensee Representative Name:       Title:      

Burden Statement

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 0596-0087. 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, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (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 (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Page 2 of 2