The following form may be filled out electronically, but when done, it needs to be signed, dated and mailed or faxed to the appropriate District Permit Officer.

District 1

Nebr. Dept. of Transportation

District 1 Permit Officer

302 Superior St

Lincoln NE 68521-2481

Phone:	(402) 471-0850

Fax:	(402) 471-3401

District 2

Nebr. Dept. of Transportation

District 2 Permit Officer

4425 S 108th St

PO Box 45461

Omaha NE 68145-0461

Phone:	(402) 595-2534

Fax:	(402) 595-1720

District 3

Nebr. Dept. of Transportation

District 3 Permit Officer

408 N 13th St

Norfolk NE 68701-3714

Phone:	(402) 370-3470

Fax:	(402) 370-3473

District 4

Nebr. Dept. of Transportation

District 4 Permit Officer

211 N Tilden

PO Box 1488

Grand Island NE 68802-1488

Phone:	(308) 385-6265

Fax:	(308) 385-6269

District 5

Nebr. Dept. of Transportation

District 5 Permit Officer

140375 Rundell Rd

PO Box 220

Gering NE 69341-0220

Phone:	(308) 436-6587

Fax:	(308) 633-6614

District 6

Nebr. Dept. of Transportation

District 6 Permit Officer

1321 N Jeffers

PO Box 1108

North Platte NE 69103-1108

Phone:	(308) 535-8031

Fax:	(308) 535-8034

District 7

Nebr. Dept. of Transportation

District 7 Permit Officer

619 Auditorium Dr

McCook NE 69001-3569

Phone:	(308) 345-8490

Fax:	(308) 345-8492

District 8

Nebr. Dept. of Transportation

District 8 Permit Officer

736 E 4th St

Ainsworth NE 69210-1215

Phone:	(402) 387-2471

Fax:	(402) 387-1498

Nebraska Department of Transportation Application for Outdoor Advertising Permit	Date of Application:
Existing Sign – Date Erected:

Attach the following to the application

1) A copy of the lease with the landowner, 2) A copy of the sketch showing the location of the sign. 3) A copy of the permit or a copy of a written approval from the Local Permit Authority that they will issue a permit for this specific sign contingent upon the Nebraska Department of Transportation issuing a permit for this specific location, 4) A sketch, drawing or photo of the sign being erected.

Name of Sign Owner:	Telephone No.:	Name of Landowner:	Telephone No.:	OFFICE USE ONLY
Address:	Address:
PERMIT NUMBER
CLASS OF SIGN APPLIED FOR ID Owned and maintained by Public Offices or III Advertising sign (Billboard). Public Agencies within their territorial jurisdiction. IVA Directional sign for qualifying attractions or IE School Bus Shelter. activities. IIA For Sale (Interstate). IVB Directional sign for qualifying organizations IIC “On Property” (Interstate). One sign per property (churches, clubs, etc.). owned by property owner. V Directional sign for farms and ranches.
Verification of Zoning of Class III Sign Location	Verification of Unzoned Class III Sign Location
Zoning Jurisdiction of: (City or County)	Jurisdiction of: (City of County)
Zoning Type: (attach copy of zoning map of the sign location)	The location where this sign is to be located is unzoned.
Commercial	Note specific zoning category:	Printed Name of City or County Clerk verifying sign location is unzoned.
Industrial	Dated:
Printed Name of Local Zoning Authority (verifying zoning of location): Dated:
Signature of City or County Clerk verifying sign location is unzoned.
Signature of Local Zoning Authority(verifying zoning of location): Dated:	Dated:
LOCATION OF ADVERTISING SIGN
County:	Hwy. No.:	Side of Hwy.: N S E W	Reference Post to Nearest Tenth of a Mile (Example 80.2):
Distance in Feet Near Edge of Sign is from the ROW line:
Legal Description:
DESCRIPTION OF SIGN	APPLICANT CERTIFICATION
Type of Sign:	I certify all information provided above is true and accurate. A permit issued pursuant to this application may be revoked and applicant’s sign removed by the Nebraska Department of Transportation at applicant’s expense if: 1. Applicant has provided false or misleading information on this application. 2. The erection of a sign pursuant to application violates State or local laws regarding zoning or violates State laws or Nebraska Department of Transportation’s rules and regulations regarding outdoor advertising.
Single Face Double Face Back-to-Back Side by Side V-Type Stacked Changeable Message Other (describe)
Supports:	Wood Steel	Number of Supports:
Face Material: Wood Metal Plastic Other:
Number of Faces:
Size (in square feet):	Printed Name of Applicant:
Length:	Height:	Area:	Signature of Applicant:	Date:
Length:	Height:	Area:
Length:	Height:	Area:	Above signature is of: Owner Officer Agent
Length:	Height:	Area:	Address of Officer or Agent:
Height above ground to top of sign in feet:
Reflectorization: Yes No Type:	Illumination: Yes No Type:
Reflectorization: Yes No Type:	Illumination: Yes No Type:	Phone No.:
Applicant Remarks:
NEBRASKA DEPARTMENT OF TRANSPORTATION, LINCOLN OFFICE USE ONLY
Fee Required: Yes No If yes, note the following check information:	Office Remarks:
Business Check Personal Check Other (describe):
Check No.: Amount: Date Received: Initial:
Staff Review (Initial and Date):	Supervisor Review (Initial and Date):
Class Approved: ID IE IIA IIC III IVA IVB V

NDOT Form 212, August 2018