Iowa Interstate Railroad Engineering Request Form

Iowa Interstate Railroad Engineering Request Form
1) Name of Licensee*
(Name ot be shown on Document)
a) If corporation
(Exact Name of Corporation)
A corporation in the State of:
NOTE: The corporate name of a company should be exactly as stated in its Articles of Incorporation. Type of Corporation, if other than a normal business corporation, MUST be shown:
(Municipal, quasi-municipal, body politic, etc.)

b) If Individual

First NameLast Name
of

CityState
c) If an individual or corporation doing business under a trade name:
(Doing Business As or Trade Name)
d) If a partnership
(Doing Business As or Trade Name)
A partnership consisting of:   First Name   Last Name
and
First Name   Last Name
all of
City   State

2) Address of Licensee*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3) Name and mailing address of individual to whom instrument is to be sent for execution if different than shown in Item 2:

First NameLast Name
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

4) Billing address if different than shown in Item 2:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5) Name and phone number of individual to contact in event of questions:
Name:   First Name*   Last Name*
Phone:   XXX-XXX-XXXX*
Email: Email*
FAX #:   Fax*
6)
a) Do you plan to utilize the right-of-way for a public use (for a utility crossing)?

YesNo
b) Do you have authority to utilize the right-of-way for a public use by condemnation?

YesNo
c) Will you initiate condemnation proceedings to acquire the subject property in the event negotiations are unsuccessful?

YesNo

7) When do you expect construction to begin on the Railroad Company's property?

MonthDayYear
Date
8) When do you need to receive this agreement from the Railroad Company?

MonthDayYear
(Please allow 30-45 days for crossings and 90-120 days for encroachments)
9) Permanent or Temporary Installation
If temporary, estimated term
Term length in months
10) Location of Installation City * Iowa Illinois*
ftft. of the line of Section:blank Township: , Range:

Latitude: 12.3456789* Longitude: -12.3456789* Milepost Start 123.123* Milepost End 123.123* (https://fragis.fra.dot.gov/GISFRASafety/)
11) New installation, relocation, or modification of existing installation which is located on the Railroad Company's property or across tracks?*
Install Type*
Location to tracks*

Contractor and Installation Information

18)
Will construction be by a Contractor?   Yes   No
If yes, Contractor will be:   First Name   Last Name
Address:   Street Address   Address Line 2   City   State   Zip
Corporate Status:   Type a label
Name and Phone Number of individual to contact in the event of questions:
First Name   Last Name   Area Code   Phone Number
19) Describe in detail the method and manner of installation on the Railroad Company's property:
Cancelof
Math Challenge
Should be Empty:

6)