INTERAGENCY REQUEST FOR TEMPORARY FLIGHT RESTRICTION
(TFR  request  must be phoned in as per FAA.  This form may also be FAXed to provide  documentation.)

RESOURCE ORDER NUMBER:  

Request #:	A -

DATE:

TIME:

TO:              FAA ARTCC ________________________________
FAA PERSON CONTACTED: _____________________________
FAA PHONE:____________________   FAX:_________________

FROM:   DISPATCH OFFICE ________________
PERSON REQUESTING TFR: __________________
24 HR. PHONE (No Toll Free #s) ___________________

	Check if this TFR is a replacement.  If so, NOTAM # of TFR being replaced. _________________________
(Existing TFRs can not be changed, only cancelled and replaced.)

Geographic Location of Incident (nearest town, state) ___________________________________________________
Location (Circular TFR)    List nearest NAVAID (distance should be less than 50 NM) - do not use NDB or T-VOR.

VOR
ID

RADIAL (Degrees)

DISTANCE (NM)

LAT/LONG of Center Point
(use US NOTAM OFFICE FORMAT ddmmssN/dddmmssW)

RADIUS (NM)
(5 NM is standard)

| | | N/                            W |

OR (Polygon TFRs should be rare and only used if circular shape is not adequate.)

Location (Polygon TFR) (List perimeter points in clockwise order) List nearest NAVAID (distance < 50 NM) - do not use NDB or T-VOR.

Point
#

VOR ID
(XXX)

Radial
(Degrees)

Distance
(NM)

Lat/Long
ddmmssN/dddmmssW

Point
#

VOR ID
(XXX)

Radial
(Degrees)

Distance
(NM)

Lat/Long
ddmmssN/dddmmssW

1 | | | | _N/                           _W | 5 | | | | _N/                           _W
2 | | | | _N/                           _W | 6 | | | | _N/                           _W
3 | | | | _N/                           _W | 7 | | | | _N/                           _W
4 | | | | _N/                           _W | 8 | | | | _N/                           _W

Altitude restrictions:   ____________  FEET MSL (do not use AGL – Standard is 2000’ above highest terrain point)

The _______________________/___________________ at _____________________ , ___________________
                           ^Agency ^Name                                 ^Incident ^Name                           ^24 ^Hr. ^Phone ^# ^(No ^Toll ^Free ^#s)               ^VHF-AM ^Air/Air ^Frequency
^is ^in ^charge ^of ^on ^scene ^emergency ^response ^activities.  ^TFR ^to ^provide ^a ^safe ^environment ^for ^fire ^fighting ^aircraft ^operations; ^effective ^immediately, ^until ^further ^notice, ^24 ^hrs/day.

The requested TFR affects the following Special-Use Airspace:
The requested TFR affects the Military Training Routes listed below:
Route | SCHEDULING ACTIVITY | SEGMENT(S) | Route | SCHEDULING ACTIVITY | SEGMENT(S)
IMPORTANT NOTE TO FAA:  If the TFR affects SUA and/or MTR(s), we request NOTAM distribution to all military bases involved, to the Coordinating Flight Service Station, and, for MTRs, to the Flight Service Station and Air Route Traffic Control Center with responsibility for the airspace at the route entry point(s).  
	
NOTAM # ________________________                        ISSUED AT ____________ (Time)    On _______/_______ (Date)

Date/Time TFR Cancelled: __________________________________________   By: ________________________________
														
Rev.09-07-02