Sd Eform 2361 - Permit Application For Business Signs On Specific And Supplemental Information Panels Form - South Dakota Department Of Transportation

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DOT256 - Rev. 12/2015
SD EForm - 2361 V2
SOUTH DAKOTA DEPARTMENT OF TRANSPORTATION
PERMIT APPLICATION FOR BUSINESS SIGNS ON SPECIFIC AND SUPPLEMENTAL INFORMATION PANELS
Name of Business
Telephone
Business Address
City
State
Zip
Billing Address
City
State
Zip
BUSINESS LOCATION DATA
1.
Highway No.:_________Interchange No:_________Intersecting Highway Numbers:_________Direction: N
S
E
W
(Circle One)
2.
Travel Distance from Nearest Interchange Exit Ramp Terminal or Highway Intersection to Business:
___________________Miles (To Nearest Tenth Mile)
SERVICE DETAILS
(Check all obtained/available/apply for each category which you are requesting signs.)
3. GAS
4. FOOD
5. LODGING
6. CAMPING
7. ATTRACTIONS
___State License
___State License
___State License
___State License
___State License
___Gasoline
___Morning Meal
___Adequate Parking
___Drinking Water
___Drinking Water
___Diesel Fuel
___Noon Meal
___Public Restroom
___Public Restroom
___Public Restroom
___Evening Meal
___Adequate Parking
___Adequate Parking
___Adequate Parking
___Adequate Parking
CATEGORY
___Amusement
___Historical
___Cultural
___Leisure
8.
Applicable License Nos. or Permit Nos.
By Whom Issued:
Date Issued:
_______________________________________
___________________________
________________________
_______________________________________
___________________________
________________________
9.
Business Hours:
From______________________A.M.
To______________________P.M.
10. Number of days a week in operation _____________ days
11. Months of Operation: From_________________________ ____________
To_________________________ ___________
Month
Day
Month
Day
12. Other Hours, Days, Months of Operation:_________________________________________________________________________
13. Type of Signs Requested:
Specific(Mainline):_________
Supplemental(Ramp):_________ Both:__________
(Applications for business signs at interchanges shall be for both a specific and a supplemental panel)
14. Sign Information For:
Eastbound Traffic __________
Westbound Traffic __________
Both __________
Northbound Traffic _________
Southbound Traffic __________
Both __________
15. Fee in Amount of $___________________ Remitted For: ________Specific Information Panels ________ Supplemental Panels
Number
Number
(NOTE: Application Fee of $50.00 Must Accompany Application For Each Specific and Each Supplemental Sign Requested.) Non-Refundable.
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
APPLICANTS CERTIFICATION
I certify that the above and foregoing statements are true and correct and I will inform the Department of any changes to the above indicated information that
may affect the availability of the service provided in accordance with State Law, Rules and Regulations. I further certify that I will not discriminate or deny
services or public accommodations based upon race, religion, color or national origin, which is prohibited by Law.
__________________________________
_____________________________________
_________________
Applicants Name (Printed)
Applicant’s Signature
Date
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
DEPARTMENT OF TRANSPORTATION USE
Region
Highway No.
Exit / Intersection
Application Fee
Date Fee Received
Annual Fee
Remarks
RECOMMENDED FOR APPROVAL:
APPROVED:
______________________________________
___________
______________________________________
____________
Region Beautification Agent
Date
Division of Operations
Date
Approval of this application shall constitute the permit contemplated by ARSD 70:01:06:.02
Distribution after approval:
Copy - Operations
Copy - Region Office
Copy - Applicant

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