Private Road Crossing Application

1. Individual or Business?
   IndividualBusiness
2. Applicant Name (required)
   
   Address (required)
   
   City (required)
   
   State (required)
   ---
   Postal Code (required)
   
   Email (required)
   
   Phone (required)
   
   Fax
   
3. Contact Name (required)
   
   Contact Phone Number (required)
   
   Contact Email (required)
   
4. If Corporation, state where incorporated
   ---
5. If Partnership, name of partners:
   
6. Other users of crossing (required)
   
7. Type of Road Crossing Required (Please check all that apply)

   Private VehiclePrivate RecreationalAt-GradeRailroad under RoadwayRailroad over RoadwayFarmResidentialRelocation/Modification of Existing CrossingIndustrial/CommercialContractor's Haul RoadNew InstallationTemporary UseUse of Existing CrossingPermanentRecreational
   If Temporary Use, how many months?
   
8. Width of roadway (required)
   
9. Location of Crossing
   
   City (required)
   
   County (required)
   
   State (required)
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10. Name of closest public road crossing (required)
    
11. Is track in cut or fill? (required)
    YesNo
    If yes, height?
    
12. Number of tracks to cross (required)
    
13. Is track on curve or tangent? (required)
    
14. Why is crossing needed? (required)
    
15. Frequency of use (# of 1-way trips daily) (required)
    
16. Types of vehicles to be driven over crossing (required)
    
17. If industrial, commercial, or contractor's haul road, type of commodities to be hauled over crossing
    
18. How is the property currently accessed? (required)
    
19. If the property was recently purchased, why was access not obtained from the seller?
    
20. Is there an existing crossing which can be removed if a new crossing is installed? (required)
    YesNo
    If yes, where is it located?
    
21. Will the crossing be accessible to the general public? (required)
    
    If not, how will access be controlled?
    
22. Is crossing covered by an existing agreement with the Railroad? (required)
    
    If so, provide the name and/or contract number
    

In making this application, I understand that if the crossing is granted, all construction work will be at my expense, and all work from end of tie to end of tie within the track area must be performed by Railroad forces at my sole expense. I understand that any relocation of utilities due to construction at the crossing will be at my sole expense. Further, I agree to assume all liability for accidents or injuries which arise as a result of the construction or use of the crossing. I further understand that I must furnish to the Railroad a current certificate of insurance evidencing coverage in the amounts of the attached insurance requirements.

I understand that before any construction begins, I must enter into a written agreement with the Railroad and prepay the estimated cost of construction. I further understand that I may be required to pay the annual license fee in advance and an administrative handling charge upon execution of the agreement.

I understand I will be responsible for all grading and approach work upon the Railroad's right-of-way up to the end of ties and will provide adequate drainage and sight distances. All future maintenance of the facilities relative to the crossing will be at my expense.

I agree that before performing any work on the Railroad's property, I will telephone the Railroad at 800-959-3215 to determine if fiber optic cable is buried anywhere on the Railroad's property to be used.

** My payment of $500.00 (minimum) for the administrative handling fee is attached. An additional installation / engineering fee may be assessed.

Please enter full name as signature:

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