Form FS-2700-10 Technical Data Sheet for Communications Uses

	USDA Forest Service FS-2700-10 (XX/202X) OMB No. 0596-0082
	USDA Forest Service Technical Data Sheet (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. 16. Applicant's Signature: Title:____________________ Date:__________ (m/dd/yyyy)
PAPERWORK REDUCTION ACT STATEMENT According to the Paperwork Reduction Act of 1995, a Federal agency may not conduct or sponsor, and a person is not required to respond to, an information collection request unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection request is 0596-0082. Response to this information collection request is required to obtain or retain benefits, specifically, a special use authorization. The authority for this information collection request is Federal Land Policy and Management Act of 1976, P. L. 94-579. The time required to complete this information collection request is estimated to average .25 hour per response, including the time for reviewing instructions, searching existing data sources, collecting and maintaining the data needed, and completing and reviewing the information collection request. Send comments regarding this burden estimate or any other aspect of this information collection request, including suggestions for reducing the burden, to Forest Service Information Collections Officer, [email protected], with OMB control number 0596-0082 in the subject line. PRIVACY ACT STATEMENT Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act statement serves to inform you of the following concerning the collection of the information on this form. Purpose:  The Privacy Act of 1974 requires that the Director of Recreation, Heritage, and Volunteer Resources staff and the Director of Lands, Minerals, and Geology Management staff provide the following statements to individuals from whom they request information. Authority:  Collection of this information solicited on this form is authorized by Federal Land Policy and Management Act of 1976, P. L. 94-579. Routine Uses:  The information collected will be used by Forest Service officials to ensure that your use of National Forest System lands is administered in accordance with applicable statutes, regulations, and directives. The information collected from you is retained in the Special Uses Data System (SUDS) and is retrieved by the Forest Service create reports for the Agency’s Special Uses Program, generate bills for collection of land use fees for your authorization, monitor compliance with your special use authorization, and other matters pertaining to administration of your special use authorization. SUDS is a component of the Forest Service’s Natural Resources Manager database (NRM). A complete list of the routine uses of NRM can be found in the system of records notice associated with this form, FS-24. Disclosure:  The submission of this information is required to obtain or retain benefits, specifically, a special use authorization. NONDISCRIMINATION STATEMENT In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs).  Remedies and complaint filing deadlines vary by program or incident. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible agency or USDA’s TARGET Center at (202) 720-2600 (voice and TYY) or contact USDA through the Federal Relay Service at (800) 877-8339.  Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all the information requested in the form.  To request a copy of the complaint form, call (866) 632-9992.  Submit the completed form or letter to USDA by (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected].  USDA is an equal opportunity provider, employer, and lender.

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