License / Permit Application

* Indicates Required Information

Project Description

Briefly describe the project and location. Give appropriate dimensions of structures, materials, elevations, depths, etc...

Project Description:	*
USACE Permit Number:

Applicant

Legal name of the party or parties to whom the license will be issued. If the responsible party is an agency, company, corporation or other organization, please indicate the responsible Corporate Officer and their title.

Company Name:	*
Corporate Officer Name:	*
Corporate Officer Title:
State Incorporated:
Business Form:
D&B D-U-N-S Number:

License Contact

Individual to serve as primary contact for the issued license.

License Contact Name:

Title:

Email Address:

Primary Phone Number:

Ext:

Alternate Phone Number:

Ext:

Street Address:

City:

State | Province | Region:

Zip Code:

Billing Address: (if different from mailing)

City:

State | Province | Region:

Zip Code:

Purchase Order: (if required)

Application Preparer

Individual physically preparing this license application. This person will be contacted with any questions regarding the application preparation.

Preparer Name:

Title:

Email Address:

Primary Phone Number:

Ext:

Alternate Phone Number:

Ext:

Agent Contact (optional)

Indicate the individual or agency, designated by you, to represent you in this process. An agent is typically an attorney, builder, contractor, or engineer, but may be any person or organization.

Agent Contact Name:

Title:

Email Address:

Primary Phone Number:

Ext:

Alternate Phone Number:

Ext:

Street Address:

City:

State | Province | Region:

Zip Code:

Emergency Contact

Individual or organization to contact in case of emergency. This phone number provided for this contact must be reachable at any time.

Emergency Contact Name:

Title:

Email Address:

Primary Phone Number:

Ext:

Alternate Phone Number:

Ext:

Street Address:

City:

State | Province | Region:

Zip Code:

Pipeline Project Data (leave blank if not a pipeline license)

Additional pipeline specific information required only for pipeline license applications.

Pipeline Name:	*
Product Type:	*
Product Transported:(specific)	*
TX RRC T-4 Number:
Installation Method:
PHA Property Impacted:
PTRA \| PHA ROW Width:
Pipeline Orientation:
This is a Valve Site:		Yes No
Valve Site Size:

Attach Documents (optional)

Electronically attach up to 3 drawings, maps, insurance certificates, or other files. Files may also be emailed after the application has been submitted if preferred.

Document 1
Description
File

By submitting this form, I certify that the all information in this application is correct.

Project Description

Applicant

License Contact

Application Preparer

Agent Contact (optional)

Emergency Contact

Pipeline Project Data (leave blank if not a pipeline license)

Attach Documents (optional)

Document 1

Document 2

Document 3