Form 10-404A Backcountry Use Permit

U .S. DEPARTMENT OF THE INTERIOR FORM 10-404A

NATIONAL PARK SERVICE OMB No. 1024-0022

Expires: XX/XX/XXXX

BACKCOUNTRY USE PERMIT

When signed, this single-visit permit authorizes:

NAME

ADDRESS

CITY STATE ZIP CODE

To Visit:

And build campfires in accordance with regulations

Give best estimate of start date (MO/DAY)

And finish date (MO/DAY)

Location of entry

Location of exit

Primary method of travel

Number of people in group

Number of pack or saddle stock

Number of watercraft or other craft

List areas to be visited, in sequence of travel, and the number of nights to be spent in each zone:

I agree to abide by all laws, rules, and regulations which apply to this area; I will do my best to see that everyone in my group does likewise.

DATE (VISITOR’S SIGNATURE)

DATE (ISSUING OFFICER’S SIGNATURE)

Paperwork Reduction Act Statement: A Federal Agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. This information is being collected to allow the park manager to make a valued judgment on whether or not to allow the requested use. All the applicable parts of this form must be completed.

Estimated Burden Statement: Public Reporting burden for this form is estimated to average 5 minutes per response, including the time it takes for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Comments regarding this burden estimate or any aspect of this form should be sent to the Special Park Uses Program Manager, National Park Service, 1849 C St., NW (2460), Washington, D.C. 20240.