Agency (Dept./Branch) Department File Number: Telephone Fax Agency File No. Plan Confirmation Number: ( ) ( ) Contact Person Client ID Number: E-Mail Address Date: Purpose of the Amendment Add Land Delete Land Revised Review Date Amend Code Amend Other Purpose Amended Code(s) Current Code(s) Land Use Restriction Restriction Exceptions(s) Agency Comments Business Account Fund Code Organization Program Code Project Code Unit Code Code Print Name Land Location Expenditure Officer Signature Name of Subdivision: Name of Subdivision: Block Lot Parcel Plan No. Block Lot Parcel Plan No. Add Land Delete Land Lands Now Required Ac/Ha Qtr/Ls Sec Twp Rge Mer Ac/Ha Sec Twp Rge Mer Ac/Ha Sec Twp Rge Mer TSS Yes No See Attached Total Acreage Conflictions Transition No. Amended Date (Y M D) Referrals Date Sent(Y M D) Date Received(Y M D) Approved Copies For Land Use Operations Rangeland Management Review Date (Y M D) Fish & Wildlife Environment Transportation For Minister Energy Municipal Authority Others Application packages can be submitted electronically to
Agency (Dept./Branch) Department File Number: Telephone ( ) Fax ( ) Agency File No. Plan Confirmation Number: Contact Person Client ID Number: E-Mail Address Date: Purpose of the Amendment Add Land Delete Land Revised Review Date Amend Code Amend Other Purpose Amended Code(s) Current Code(s) Land Use Restriction Restriction Exceptions(s) Agency Comments Business Unit Account Code Fund Code Organization Code Program Code Project Code Print Name Expenditure Officer Signature Land Location Name of Subdivision: Name of Subdivision: Plan No. Block Lot Parcel Plan No. Block Lot Parcel Add Land Delete Land Lands Now Required Ac/Ha Qtr/Ls Sec Twp Rge Mer Ac/Ha Sec Twp Rge Mer Ac/Ha Sec Twp Rge Mer TSS Yes No See Attached Conflictions Transition No. Total Acreage Referrals Date Sent(Y M D) Date Received(Y M D) Approved Copies For Amended Date (Y M D) Land Use Operations Rangeland Management Fish & Wildlife Review Date (Y M D) Environment Transportation Energy For Minister Municipal Authority Others Application packages can be submitted electronically to
Reserve-NotationAmendment-Feb2017A.docx