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AV-4 2-12 APPLICATION FOR NEW AIRPORT/HELIPORT SITE APPROVAL www. dot. state. pa.us PLEASE TYPE OR PRINT IN BLUE OR BLACk INk SHADED AREAS ARE FOR BUREAU USE ONLY APPLICATION FEE 50 I We hereby make application for license to operate an Airport/Heliport and affirm that I am we are the Owner s Lessee s of the property. DATE POINT OF CONTACT if different than Licensee NAME OF LICENSEE EMAIL DAYTIME PHONE NUMBER STREET ADDRESS/P. O. BOX CITY STATE Z.

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