Agricultural Landowner Permission Slip

For Relay Tower Installation

Landowner Name

Address of Landowner

Phone Number

Email Address

Location of Agricultural Land (Description/Address/Coordinates)

Details of Relay Tower to be Installed

Period of Permission (From — To)

Special Conditions / Notes (if any)

Landowner Consent

I, the undersigned, hereby give permission for the installation and maintenance of a relay tower on my agricultural land as detailed above.

Landowner Signature

Date

Witness Name

Witness Signature

Date