REQUEST FOR A TEMPORARY FLIGHT RESTRICTION

DATE: _______________________________

TIME:   _______________________________	FAA ARTCC requires phone notification. 
ARTCC  _____________________________________
FAA PHONE:______________FAX:_________________
	
Resource 
Order Number:   __________________________________ 

Request Number: 	A -_______	DISPATCH OFFICE __________________________
PERSON REQUESTING TFR: __________________
24 HR. PHONE (No Toll Free #s) ___________________ 	
 Circular     Degrees Minutes Seconds Only – use zero’s for seconds if unavailable	
LAT/LONG of Center Point
(US NOTAM OFFICE FORMAT ddmmssN/dddmmssW)	RADIUS (NM)
(5 NM is standard)	
N/                            W		
  Polygon  (List perimeter points in clockwise order).  For  NES Input:  Use the same NAVAID if possible for each point.  List nearest               
NAVAID (distance < 50 NM) - do not use NDB or T-VOR.    (For lat/long - Degrees Minutes Seconds only)	
Point
#	Lat/Long format
ddmmssN/dddmmssW	Point
#	Lat/Long format 
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	

NOTAM # of TFR being replaced_______________________
Altitude (MSL: Only) _____________________
24 hours a day? ___________    or Daytime Operational Hours: (UTC)  ______________to ________________  
Incident TFR Duration:____________________ to _______________ (Estimate – 2 months out is ok)
Format:                           YYMMDDhhmm            to    YYMMDDhhmm  

   Geographic Location of Incident (NM from nearest well known location recognizable to general aviation or local town, state)
    _____________________________________
   
Agency in Charge ___________________________________ Incident Name __________________________
24 hour phone number (No toll Free #s) ________________    VHF-AM Air to Air Frequency ________________ 
  This will affect the following Special-Use Airspace:  (MOA, RA, WA, PA, AA):_____________________________

This will affect the following  Military Training Routes:	
Route	SEGMENT(S)	SCHEDULING ACTIVITY	Route	SEGMENT(S)	SCHEDULING ACTIVITY	

NOTAM # ________________________ Time Issued  ____________ Date _______/_______/______   	

  Date/Time TFR Canceled: ______________   By: ________________ Replaced by ________________________________