Form 10-404A Backcountry Use Permit

U.S. DEPARTMENT OF THE INTERIOR
NATIONAL PARK SERVICE

FORM 10-404A
OMB Control No. 1024-0022
Expires: XX/XX/XXXX

BACKCOUNTRY USE PERMIT

Name (Last, First, MI): ____________________________________________________________________
Street Address: __________________________________________________________________________
City, State, Zip: ______________________________________________ Country: ___________________
Day Phone: ___________________ Evening Phone: ___________________ Fax: ___________________
Email Address: __________________________________________________________________________
Emergency Contact Information:
Name: __________________________________________ Phone Number: ______________________
Do you have an America the Beautiful Pass? Yes / No (Circle One) If yes, pass #: _____________________
Do you have an Interagency Access or Senior Pass? Yes / No (Circle One) If yes, pass #: _______________
Type of backcountry use requested:
General Camping

Group Camping

Backpacking

Climbing

Mountain Biking

Mountaineering

OHV

_______________________

__________________________

Is this an organized or guided trip? Yes / No (Circle One)
Group/Organization Name: ______________________________________________________________
CUA or RPRS#: __________________
# of trips requested: ____________ # of people per trip: ____________
# of applications: ____________ (For large groups with multiple applications)
Number of stock: ____________ Type of Stock: ___________________________________
Number of boats: ____________ Type of Boat: ____________________________________

Method of Travel:
Foot/Backpacking

Mountain Biking

Ski

4WD/Motorcycle (Day Use)

4WD/Motorcycle (Camping)

Snowshoe

Motorboat (motorized)

Motorboat (motorized)

Sailboat

Climbing

SCUBA

Stock

Drop-Off by Stock

Drop-Off by Boat

Drop-Off / Other

River Rafting – Motor

River Rafting – Hand Propelled

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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 Information Collection Clearance Officer, National Park Service, 1849 C St., NW (2601), Washington, D.C. 20240.

Launch Site:______________________________________________________________________________
Take Out Information:______________________________________________________________________
Vehicle #1
State:_______________________________
Plate #:______________________________
Make:_______________________________
Model:_______________________________
Color:________________________________
Parking location:_____________________________________________________
Rental vehicle (yes/no)
Vehicle #2
State:________________________________
Plate #:_______________________________
Make:________________________________
Model:________________________________
Color:_________________________________
Parking location:______________________________________________________
Rental vehicle (yes/no)
First Choice:
Start Date:______________________
End Date:_______________________
Entry location:____________________
Exit location:_____________________
Length of stay (# of nights):___________________________
Use Area or Campsite:_______________________________
Night 1 (date, code, campground, trail):____________________________________
Night 2 (date, code, campground, trail):____________________________________
Night 3 (date, code, campground, trail):____________________________________
Night 4 (date, code, campground, trail):____________________________________
Night 5 (date, code, campground, trail):____________________________________
Night 6 (date, code, campground, trail):____________________________________
Night 7 (date, code, campground, trail):____________________________________
Second Choice:
Start Date:_______________________
End Date:________________________
Entry location:_____________________
Exit location:______________________
Length of stay (# of nights):___________
Use Area or Campsite:______________________________
Night 1 (date, code, campground, trail):_____________________________________
Night 2 (date, code, campground, trail):____________________________________
Night 3 (date, code, campground, trail):____________________________________
Night 4 (date, code, campground, trail):____________________________________
Night 5 (date, code, campground, trail):____________________________________
Night 6 (date, code, campground, trail):____________________________________
Night 7 (date, code, campground, trail):____________________________________

Third Choice:
Start Date:_______________________
End Date:________________________
Entry location:_________________________________________________________
Exit location:__________________________________________________________
Length of stay (# of nights)___________
Use Area or Campsite:__________________________________________________
Night 1 (date, code, campground, trail):_____________________________________
Night 2 (date, code, campground, trail):_____________________________________
Night 3 (date, code, campground, trail):_____________________________________
Night 4 (date, code, campground, trail):_____________________________________
Night 5 (date, code, campground, trail):_____________________________________
Night 6 (date, code, campground, trail):_____________________________________
Night 7 (date, code, campground, trail):_____________________________________
Additional Choices:
(If all choices above are unavailable, the Backcountry
Information Center will retry using options selected below)
□ Similar/nearby campsites
□ Reverse route
# of Campsites
Trip Length (# of nights):__________________
Group Size:____________________________
Minimum Group Size:____________________
Alternate Start Dates:____________________
Earliest Start Date:______________________
Latest Start Date:_______________________
Technical Canyoneering and Pack Rafting
(check box if listed gear will be used)
□ Technical gear to descend slot canyons
□ Pack Raft or similar
Beginning Trailhead:_____________________________________________________
Ending Trailhead:________________________________________________________

Itinerary (Select one from below):
□ _______________________________
□ _______________________________
□ _______________________________
□ _______________________________
□ _______________________________
□ _______________________________
□ _______________________________
□ _______________________________
□ _______________________________
□ _______________________________

Frequent Hiker Membership:
(waives the $10 permit fee for 12 months from date of purchase):
□ I am already a member
□ Please enroll me for 1 year/$25
□ No thanks
□ Use hiker credit on file
Method of Payment:
□ Check
□ Money Order
□ MasterCard □ Visa □ Discover □ Discover □ American Express
Name on Card:_______________________________
Billing Address, City, State, Zip:____________________________________________
Billing Phone #:______________________
Card CVC Code #:___________________
Expiration Date:_____________________
Security Code:______________________
Total Cost:_________________________
Signature:_________________________________________
Remarks:_______________________________________________________________________________
Special Instructions:_____________________________________________________________________

Permit Conditions:
□ Travel in ___________ backcountry has inherent risks and hikers assume complete
responsibility
for their own safety. Rescue is not a certainty. Backcountry users should be in good physical condition and
should be able to survive on their own by taking the necessary precautions and equipment. Your safety is
your responsibility.
□ In large camping areas, camps should be 200 feet from streams and trails and 1/4 mile from springs.
Camping in previously used areas or on bare ground is encouraged.
□ Backcountry groups are limited to a maximum of 24 people sharing the same affiliation, scout troop, family,
friends in the same area, route, or trail, on the same day. Your permits will be denied and/or you will receive a
ticket if you are in violation of this regulation. This regulation is strictly enforced.
□ Pets must be on a leash at all times.
□ All natural objects and cultural artifacts are protected and must be left where they are found.
□ Human waste should be buried at least 6 inches deep and whenever possible, 200 feet away from water,
dry wash areas, or designated campsites. All trash, including toilet paper, should be packed out.
□ Purify all water before drinking.
□ I have read and fully understand the rules associated with my trip and I agree to comply accordingly.

Failure to comply with regulations will result in revocation of this permit and a fine._____
□ I will contact the Park Fee Office at ______________ if there is a reduction in my group size or
cancellation of a trip.
□ I will notify the backcountry office at ______________ if my vehicle or emergency contact information
changes. Failure to do so will delay search and rescue efforts.
□ I will print and carry my permit with me, and I will advise a friend or family member to notify the National
Park Service if I am overdue.
□ Use the standard method of hanging backpacks and food sacks at least 10 feet off the ground and 4 feet
away from the tree trunk.
□ Any food not in use should be stored in this manner while in the backcountry. Plan your meals carefully so
excess food is not left over.
□ Do not sleep in clothes you have cooked in, as the food odor left on your clothes may attract a bear.
Consider cooking some distance from your sleeping area.
□ Leave No Trace outdoor ethics are encouraged.
□ No pets are allowed in the backcountry or wilderness areas.
Great Smokey Mountain National Park:
Appalachian Trail Thru-Hiker Backcountry Permit:
□ I certify that I am beginning and ending my trip more than 50 miles outside of park and hiking/camping
only on the AT while in the park.
AT Thru-Hiker Direction:
□ Northbound
□ Southbound
Estimated date you will begin your hike through _________________ National Park.
_____________ (Specify an entry date)
Yellowstone National Park:
□ Will use Yellowstone Lake boat shuttle to camp on:
□ boat
□ shore
Yosemite National Park:
I would like to hike to the top of Half Dome while on this overnight wilderness trip. Please reserve Half
Dome Permits for an additional $8.00 per person, payable when I pick up my wilderness permit. (Check)
□ No □ Yes
# of Half Done Permits __________
If Half Dome permits are NOT available for my trip (check):

□ Please do NOT process this reservation
□ Make this wilderness permit reservation without Half Dome permits. I understand that there are no
refunds for wilderness permit reservations
□ Own Canister
□ Bear Lockers (HSC/LYV Only)
□ Number of canisters
Winter Self-Registration:
Equipment Carried (Example: stove, sleeping bag, bivy sack, shovel, skins).
List gear items:
_____________________________________________________________________________________
_____________________________________________________________________________________
Trip leader's signature:_________________________________________