Outdoor Advertising Permit Transfer Application

APPLICATION FOR TRANSFER

OF OUTDOOR ADVERTISING PERMIT(S) IN ACCORDANCE WITH 7 CSR 10-6.070

MISSOURI DEPARTMENT OF TRANSPORTATION

PART I: PERMIT OWNER INFORMATION New Owner Name: Previous Owner Name:

Contact Person: Contact Person:

Mailing Address: Mailing Address:

City: State: Zip Code: City: State: Zip Code:

Telephone Number: Telephone Number:

Email Address:

Billing Email Address: PART II: PERMIT(S) TO BE TRANSFERRED – Attach additional pages if necessary

MoDOT Sign Permit Company Date of Number Number Purchase Land Owner Name Land Owner Address

PART III: CURRENT DESCRIPTION OF OUTDOOR ADVERTISING STRUCTURE – Attach additional pages if necessary All permit holders should contact the area specialist, in writing, prior to making any changes to a structure.

MoDOT Status Size: Does the Permit (Conforming, Height by Sign have Current Current City Limits Number Nonconforming Width Lighting? Configuration Technology Zoning (within city limits?) or Conforming Out of Standard)

X X X X

______Signature of New Owner Print Name Date

Our mission is to provide a world-class transportation experience that delights our customers and promotes a prosperous Missouri. The appropriate documentation must be provided as well as NOTARIZATION ON THE BACK of this completed form and transfer fee(s), or the application will be returned. The area specialist may request additional information in order to process this application.

Enclose the following with your application: A check in the amount of $10.00 per sign permit to be transferred, payable to: Director of Revenue, Credit State Road Fund. A letter or bill of sale from previous owner reflecting the permit number(s) for each permit being transferred.

The applicant, by signature, agrees that the information provided in this application is complete and accurate.

STATE OF , County of

, being of lawful age and first duly sworn, upon his oath deposes and states: (Name of Applicant)

CHECK ONE:

( ) That I am the above-mentioned individual.

( ) That I am the of which is organized under the laws of (title) (name of corporation) , with its principal office and place of business in , ; (state) (city, state) and that I have the power and authority for and on behalf of said corporation to make this affidavit and in its behalf, and do so make same.

( ) That I am the of which is not a corporation and that I have (title) (name of firm) the power and authority for and on behalf of said firm and its members and owners to make this affidavit for in its and their behalf, and do so make same.

That I have read the foregoing and that the facts set out therein are true and correct to the best of my knowledge and belief.

______Signature of Applicant

Subscribed and sworn to before me this ______day of ______, 20 ______.

My Commission expires: ______Notary Public

Mail the completed application, enclosures, and payment to the area specialist for the county in which the sign structure is located.

General and financial questions, contact the Outdoor Advertising Technician at: 573-522-1725 or [email protected]

Area 1 (816) 387-2504 Area 2 (573) 751-7187 Area 3 (314) 453-1870 Missouri Department of Transportation Missouri Department of Transportation Missouri Department of 3602 North Belt Hwy PO Box 718 Transportation St. Joseph, MO 64506 Jefferson City, MO 65102 1590 Woodlake Drive Attn: Outdoor Advertising Permit Specialist Attn: Outdoor Advertising Permit SpecialistChesterfield, MO 63017-5712 Attn: Outdoor Advertising Permit Specialist Counties: Counties: Counties: Andrew, Atchison, Buchanan, Caldwell, Cass, Clay, Adair, Audrain, Boone, Callaway, Carroll, Chariton,Crawford, Franklin, Gasconade, Jefferson, Clinton, Daviess, DeKalb, Gentry, Harrison, Holt, Clark, Cole, Cooper, Grundy, Howard, Knox, Lewis,Lincoln, Marion, Montgomery, Pike, Ralls, Jackson, Johnson, Lafayette, Nodaway, Pettis, Linn, Livingston, Macon, Mercer, Moniteau, Monroe,St. Charles, Platte, Ray, Worth Osage, Putnam, Randolph, Saline, Schuyler, Scotland,St. Louis, St. Louis City, Warren, Shelby, Sullivan Washington

PERMITTRANSFER Revised 06/2016 Area 4 (417) 895-7648 Area 5 (417) 895-1333 Area 6 (573) 472-5352 Missouri Department of Transportation Missouri Department of Transportation Missouri Department of PO Box 868 PO Box 868 Transportation Springfield, MO 65801 Springfield, MO 65801 PO Box 160 Attn: Outdoor Advertising Permit Specialist Attn: Outdoor Advertising Permit SpecialistSikeston, MO 63801 Attn: Outdoor Advertising Permit Specialist Counties: Counties: Counties: Barry, Barton, Christian, Dade, Douglas, Greene, Howell, Bates, Benton, Camden, Cedar, Dallas, Bollinger, Butler, Cape Girardeau, Carter, Dent, Jasper, Lawrence, McDonald, Newton, Ozark, Stone, Taney, Henry, Hickory, Laclede, Maries, Miller, Dunklin, Iron, Madison, Mississippi, New Madrid, Texas, Webster, Wright Morgan, Phelps, Polk, Pulaski, St. Clair, Oregon, Pemiscot, Perry, Reynolds, Ripley, Vernon St. Francois, Ste. Genevieve, Scott, Shannon, Stoddard, Wayne

Additional forms and information available at http://www.modot.org/business/Outdoor_Advertising

PERMITTRANSFER Revised 06/2016