Form 2920-1 Land Use Application and Permit

Form 2920-1

(February 2005)

FORM APPROVED
OMB NO.1004-0009
Expires: December 31, 2007

UNITED STATES
DEPARTMENT OF THE INTERIOR

FOR BUREAU OF LAND MANAGEMENT (BLM) USE ONLY

BUREAU OF LAND MANAGEMENT

LAND USE APPLICATION AND PERMIT

Application Number

(Sec. 302(b) of P.L. 94 - 579, October 21, 1976, 43 U.S.C. 1732)

1. Name (first, middle initial, and last)

Address (include zip code)

Phone (include area code)

2. Attach map or sketch showing public lands for which you are applying
to

3. Proposed date(s) of use: from
4. Give legal basis for holding interest in lands in
the State of

Resident
Corporation
Local Government
Other

(Check appropriate box at right and explain.)

5. Are the lands now improved, occupied or used?

6. Do you need access to the land?

Yes

Yes

Partnership
County
State Government

No (If "yes," describe improvements and purposes, identify users and occupants.)

No (Describe needed or existing access)

7a. What do you propose to use the lands for?

b. What improvements and/or land development do you propose? (To complete application processing, engineering and construction drawings
may be required)

c. What is the estimated capital cost?

d. What is the source of water for the proposed use?

$ _________________________________

I CERTIFY That the information given by me in this application is true, complete, and correct to the best of my knowledge and belief and is given in good faith.

(Signature of Applicant)

(Date)

Title 18 U.S.C. Section 1001, makes it a crime for any person knowingly and willfully to make to any department or agency of the United States
any false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction.
(Continued on page 2)

PERMIT
Permit Number

Permission is hereby granted to
of
to use the following described lands:
TOWNSHIP

Meridian

RANGE

SECTION

SUBDIVISION

State

County

Acres (number)

for the purpose of
and subject to the following conditions:
1. This permit is issued for the period specified below. It is revocable
at the discretion of the BLM, at any time upon notice. This
permit is subject to valid adverse claims heretofore or hereafter
acquired.
2. This permit is subject to all applicable provisions of the regulations
(43 CFR 2920) which are made a part hereof.
3. This permit may not be assigned without prior approval of the
BLM.
4. Permittee must not enclose roads or trails commonly in public use.
5. Authorized representatives of the Department of the Interior, other
Federal agencies, and State and local law officials will at all times
have the right to enter the premises on official business.
6. Permittee must pay the United States for any damage to its property
resulting from the use.
7. Permittee must notify the BLM of address change
immediately.
8. Permittee must observe all Federal, State, and local laws and
regulations applicable to the premises and to erection or
maintenance of signs or advertising displays including the
regulations for the protection of game birds and game animals, and
must keep the premises in a neat, orderly, and sanitary condition.
9. Permittee must pay the BLM, in advance, the lump sum of
for the period of use authorized
$

by this permit or $
, annually, as rental or
such other sum as may be required if a rental adjustment is made.
10. Use or occupancy of land under this permit will commence within
months fromdate hereof and must be exercised at least
days each year.
11. Permittee must take all reasonable precautions to prevent and suppress
forest, brush, and grass fires and prevent pollution of waters on or in
the vicinity of the lands.
12. Permittee must not cut any timber on the lands or remove other
resources from the land without prior written permission from the
BLM. Such permission may be conditioned by a requirement
to pay fair market value for the timber or other resources.
13. Permittee agrees to have the serial number of this permit marked or
painted on each advertising display or other facility erected or
maintained under the authority of such permit.
14. This permit is subject to the provisions of Executive Order No. 11246
of September 24, 1965, as amended, which sets forth the Equal
Opportunity clauses. A copy of this order may be obtained from the
BLM.
15. Permittee acknowledges, by signing below, that he/she knows,
understands and accepts the terms and conditions under which this
permit is issued.

16. Special conditions (attach additional sheets, if necessary)

Permit issued for period
(Permittee)

From

(BLM)

To

(Date)

(Title)

INSTRUCTIONS

1. Submit, in duplicate, to any local office of the Bureau of Land
Management having jurisdiction of the lands.
2. Applications for Land Use Permits will not be accepted unless a
notification of the availability of the land for non-BLM use (Notice of
Realty Action) has been published in the Federal Register and for 3
weeks thereafter in a newspaper of general circulation. This
provision does not apply in those situations where the publication of

(Continued on page 3)

a (Notice of Realty Action) has been waived by the BLM.
3. If the annual rental exceeds $250 dollars per year; costs of processing
the application must be paid by the applicant in advance.

4. The BLM may require additional information to process
an application. Processing will be deferred until the required
information is furnished by the applicant.

(Form 2920-1, Page 2)

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 for a Land Use
Permit.
AUTHORITY: 43 U.S.C. 1201; 43 CFR Part 2920
PRINCIPAL PURPOSE: The information is to be used to process your application.
ROUTINE USES: (1) The adjudication of the applicant's request for a Land Use Permit. (2)
Documentation for public information. (3) Transfer to appropriate Federal agencies when concurrence
is required prior to granting a right in public lands or resources. (4)(5) Information from the record
and/or the record will be transferred to appropriate Federal, State, local or foreign agencies, when
relevant to civil, criminal or regulatory investigations or prosecutions.
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the information is voluntary. If all
the information is not provided, the application may be rejected.
The Paperwork Reduction Act of 1995 requires us to inform you that:
Information is needed to process application for land use authorizations, pursuant to 43 CFR Section
2920.
Information shows if the applicant and proposed user meet the requirements of 43 CFR Section
2920.1.
Applicant must respond before he/she can be granted an authorization to use public lands.
BLM would like you to know that you do not have to respond to this or any other Federal agencysponsored information collection unless it displays a currently valid OMB control number.
BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average
1 hour per response for the majority of responses, including the time for reviewing instructions,
gathering and maintaining data, and completing and reviewing the form. For proposed uses the
scope of which is more complex, the public reporting burden is estimated to average 120 hours
per response. Direct comments regarding the burden estimate or any other aspect of this form to
U.S. Department of the Interior, Bureau of Land Management (1004-0009), 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 2920-1, page 3)