Form 2930-1 Special Recreation Application and Permit

NOTICES
The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) provide that you be furnished the following
information, in connection with information required by this application.
AUTHORITY: 43 U.S.C. 1201; 43 CFR Group 2930.
PRINCIPAL PURPOSE: BLM will use the information you provide to determine whether or not to issue you a
Special Recreation Permit. BLM will use some of the information to determine your qualifications for the
permit and the other information to determine the merits of your proposal.
ROUTINE USES: BLM will disclose the information according to the release information contained in the
regulations at 43 CFR 2.56(d).
EFFECT OF NOT PROVIDING INFORMATION: Disclosing the information is necessary to receive a benefit.
Not disclosing the information may result in the BLM's rejecting your application.
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM will use the information to determine whether or not to issue you a Special Recreation Permit.
Response to this request is required to obtain a benefit.
BLM would like you to know that you do not have to respond to this or any other Federal agency-sponsored
information collection unless it displays a currently valid OMB control number.

BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average 30 minutes
per response, including the time for reviewing instructions, gathering and maintaining data, and completing and
reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to U.S.
Department of the Interior, Bureau of Land Management (1004-0119), Bureau Information Collection Clearance
Officer (WO-630), 1849 C Street, N.W., Mail Stop 401 LS, Washington, D.C. 20240.

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(Form 2930-1, page 3)