0596-0087 License Amendment/Renewal

Commercial Use of the Woodsy Owl Symbol - 36 CFR Part 272

0596-0087 LicenseAmendment-renewal11152019

License Applications, Renewals, and Amendments (Benefits)

OMB: 0596-0087

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US Forest Service (v05-2019)

OMB Control No. 0596-0087 Exp. Date:


Shape1

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.


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