Osage Nation Burn Permit Application

Permit No.
LAND OWNER'S INFORMATION
Name Name First Last
Phone Phone - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
County
Ranch Name (if any):
Description of area where burn will occur:
Approximate size of burn:
Legal description of location:
Latitude:
Longitude:
Projected time frame:
Type of Burn
PARTY RESPONSIBLE FOR BURN
Name:
Phone Phone - ### - ### ####
Fire Department Name:
Adjoining landowners:
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.