Form 10-404 Backcountry/Wilderness Use Permit Application

NPS Form 10-404 (Rev. 04/2017) OMB Control No. 1024-0022

National Park Service Expiration Date XX/XX/2020

BACKCOUNTRY/WILDERNESS USE PERMIT APPLICATION

[PARK]

[Name of Permits Program Office]

[Address]

[City, ST Zip Code]

Telephone: (###) ###-####

[NOTE TO PARKS: The fields in the “Applicant Information Section” below and records retention statement in the footer are mandatory for every park to show on their form. You may not change any fields and you may not add any fields to the list. Changes or additions must be approved by OMB through the Bureau Information Collection Clearance Officer, Tim Goddard [970-420-9590]

APPLICANT INFORMATION (All Fields Mandatory for Every Park)

When approved by NPS park official, this single-visit permit authorizes:

Last Name

First Name

MI

Suffix

     

     

     

     

Street Address

     

City

State

Zip Code

Country

     

     

     

     

[NOTE TO PARKS: You may select from information fields below to customize your park-specific permit. With the exception of the fields in the “Applicant Information Section” above and records retention statement in the footer which are mandatory for every park to show on their form, you do not have to use and may remove any of the remaining fields. You may not change any fields and you may not add any fields to the list. Some fields may need to be replicated multiple times to accommodate multiple responses (e.g., method of travel, emergency points-of-contact, itinerary, etc.) Changes or additions must be approved by OMB through the Bureau Information Collection Clearance Officer, Tim Goddard [970-420-9590]

MISCELLANEOUS INFORMATION

For the purposes of improving your visit, the National Park Service may seek to understand more about your visitor experience on this Wilderness/Backcountry trip.  Are you willing to allow your contact information be used to follow up on social science information needs by the NPS in the future?  Yes                No

Contact Phone

Home Cell Work

Email Address

     

     

Date of Birth

Fax Number (Optional)

Driver’s License/Identification Number

Issuing State

Issuing Country ( U.S.)

     

     

     

     

     

Do you have an America the Beautiful Pass? Yes No

Do you have an Interagency Access or Senior Pass? Yes No

If “Yes”, pass #:      

If “Yes”, pass #:      

Group/Organization Type (Boy Scouts, CUA, SUP, Church group, etc.)

No. of Permit Requests (For large groups with multiple applications)

     

          

Group Name

No. of Trips Requested

No. of People Per Trip

     

     

     

Is this an organized or guided trip?

# of People in Party (Max ##)

# of Youth (## and Under)

# of Adults (## and Older)

Yes No

     

     

     

Frequent Hiker Membership (Waives the $___ permit fee for ___ months from date of purchase)

I am already a member

No Thanks

Please enroll me for ___ year/$____

Use hiker credit on file

Commercial Use Authorization (CUA) Permit #

Research Permit and Reporting System (RPRS) Permit #

     

     

Emergency Point-of-Contact Name

Family Friend

Emergency Point-of-Contact Phone Number

Emergency Point-of-Contact City/State

     

     

     

TYPE OF BACKCOUNTRY USE REQUESTED (Check All That Apply) *Prohibited in Wilderness Areas

General Camping

Backpacking

Mountaineering

Cross Country Skiing/Snowshoeing

Group Camping

Canyoneering/Rappelling

High Altitude Climbing

Mountain Biking *

Bouldering

Hunting

Rock Climbing

Off-Road Vehicle (ORV) *

Stock

Type of Pack or Saddle Stock

Number of Stock

River Use

Number of People

Indicate Type and/or Location of Use

     

     

     

     

METHOD OF TRAVEL (Check All That Apply) *Prohibited in Wilderness Areas

Foot/Backpacking

Mountain Biking *

Ski

Snowshoe

SCUBA

Climbing (List gear in equipment list)

Canyoneering (List gear in equipment list)

Stock

Drop-Off by Stock

Kayak

Watercraft (Indicate Type:

Motorized * Non-motor  Hand propelled Non-motor support

Snowmobiling *

4WD/Motorcycle (Camping) * (Describe vehicle in “Mode of Transportation” section)

4WD/Motorcycle (Day Use) * (Describe vehicle in “Mode of Transportation” section)

Other (provide details)      

MODE OF TRANSPORTATION

Vehicle (Including 4WD/Motorcycle)

Snowmobile

State

     

Plate #

     

State

     

Plate #

     

Make

     

Model

     

Make

     

Model

     

Color

     

Rental?

Yes No

Color

     

Rental?

Yes No

Parking Location      

Parking Location      

Aircraft

Off-Road Vehicle (ORV)

State

     

N-Number

     

State

     

Plate #

     

Make

     

Model

     

Make

     

Model

     

Color

     

Rental?

Yes No

Color

     

Rental?

Yes No

Parking Location

     

Watercraft (Includes boats, canoe, kayak, river raft, packraft, etc.)

(Not used)

State

     

Hull Reg. #

     

Type

     

Make

     

Model

     

Size (Feet)

     

Color

     

Rental?

Yes No

Launch Site

     

Take Out Location

     

Launch Date

     

Take Out Date

     

Trailer Parking Location

     

EQUIPMENT Fields marked with an * are check-off only *Please See Notices Section for Additional Information

Approved Bear Resistant Food Storage Container *

Avalanche Shovel *

Avalanche Probe Poles *

Avalanche Transceiver *

Camp Stove *

Climbing Rope (length      )

Compass *

Fire Starter *

GPS Unit *

Human Waste Disposal/Pack Out System *

Ice Axe *

Map *

Skis *

Snowshoes *

Supplemental Oxygen *

Water Purification Device/System *

Whistle *

Other equipment (specify)

Climbing Hardware

List All Hardware

     

Cellular Telephone * (include type, service provider, & quantity)

Type

Service Provider

Quantity

     

     

     

Satellite Telephone * (include type, service provider, & quantity)

Type

Service Provider

Quantity

     

     

     

Personal Locator Beacon or Device * (include type and service provider)

Type

Service Provider

     

     

Radio

Type

Frequency(ies)

     

     

Emergency signaling devices

Type

Quantity

U.S. Air Force type signal mirror

     

Signal panel

     

Other (list):      

     

Tent or Shelter (Including hammock)

Type

Color

Quantity

     

     

     

ATV

Type

Color

Quantity

     

     

     

Bicycle

Type

Color

Quantity

     

     

     

Snow Sled/Sledge

Type

Color

Quantity

     

     

     

Water Craft or Vessel (including kayak and canoe)

Type

Color

Quantity

     

     

     

Aircraft

Type

Color

N-Number

     

     

     

Pack & Saddle Stock

Type

Quantity

     

     

First Aid Kits

Type

Quantity

Minor

     

Major

     

U.S. Coast Guard Approved Life Jackets

Type

Quantity

Offshore Lifejacket - Type 1

     

Near Shore Buoyant Vest - Type II

     

Flotation Aid - Type III

     

Throwable Device - Type IV (includes boat cushions, ring buoys, and horseshoe buoys)

     

Special Use Device - Type V (includes include work vests, deck suits, and hybrids for restricted use)

     

Inflatable Life Jackets

     

Backpack

Type

Color

     

     

Footwear

Type

Size

     

     

Dog Team/Sled

# of Dogs

     

ITINERARY DETAILS

Start Date

End Date

Entry Location

Exit Location

     

     

     

     

Date

[Campground/Trail Name or Code]

Night 1 - Date

     

     

Night 2 - Date

     

     

Night 3 - Date

     

     

Night 4 - Date

     

     

Night 5 - Date

     

     

Night 6 - Date

     

     

Night 7 - Date

     

     

Additional Choices: If all choices above are unavailable, the Backcountry Information Center will retry using options selected below:

# of Campsites

Trip Length (# of nights)

Group Size

Minimum Group Size

     

     

     

     

Flexible Itinerary?

Similar/Nearby Campsites Reverse Itinerary

Alternate Dates

Earliest Start Date

Latest Start Date

Yes No

      to      

     

     

PAYMENT INFORMATION
Name on Card									Billing Phone Number
     									     
Billing Address				City		State			Zip Code	Country
     				     		     			     	     
Method of Payment Check Money Order MasterCard Visa Discover American Express
Credit Card Number			Expiration Date		CVC Code # (3 digits)		Total Amount Authorized
     			     		     		$      
Signature							Date
							     
MISCELLANEOUS
Remarks	     
Special Instructions	     
Visitor’s Signature		Date		Issuing Officer’s Signature				Date/Time

(PARK SPECIFIC FIELDS – TO BE USED ONLY BY THE SPECIFIED PARKS)

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 Date)
		          

YELLOWSTONE NATIONAL PARK
I will use the Yellowstone Lake boat shuttle to camp on:
Boat	     	Shore	     

YOSEMITE NATIONAL PARK
Half Dome
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) Yes No											Number of 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
Half Dome Lottery
Group Leader Information							Alternate Group Leader Information
Group Leader			Date of Birth				Group Leader		Date of Birth
Applying For
Facility					Permit Type			Entrance
Preferred Choice							Alternative Choice 1
Permit Entry Date			Permit Group Size				Permit Entry Date		Permit Group Size
Donohue Pass
I would like to exit over Donohue Pass on this overnight wilderness trip. Yes No
If the Donohue Pass Exit quota is NOT available for my trip (check):				No Please do NOT process this reservation
				Make this wilderness permit reservation without the Donohue Pass Exit. I understand that there are no refunds for wilderness permit reservations
	Own Canister
	Bear Lockers (HSC/LYV Only)
	Rented Canister (Include canister numbers)
Make/Model of Bear Canister(s)      
Will the trail you are traveling on exit Yosemite National Park and enter a different wilderness area? Yes No
I have read and agree to the Yosemite Camping rules and regulations. I have read the terms and conditions.
Winter Self-Registration
Equipment Carried (Example: stove, sleeping bag, bivy sack, shovel, skins). List all gear items (to include make/model/color):
     
Trip leader's signature										Date

GRAND CANYON NATIONAL PARK

Please provide desert and/or Grand Canyon hiking experience.

     

Daily Itinerary Details (use additional pages if necessary)

Date

Daily Mileage (very important)

Trail / Route to be Taken / Camp Location / Use Area

Night 1

     

     

     

Night 2

     

     

     

Night 3

     

     

     

Night 4

     

     

     

Night 5

     

     

     

Night 6

     

     

     

Night 7

     

     

     

River Trip Leader Information (Permit Applicant)

Date of most recent recreational Colorado River trip

User name

Password

     

     

     

To be notified via email about the main lottery or any follow-up lotteries, you MUST CHOOSE TO OPT-IN by checking the corresponding boxes below.

Annual Lotteries: I want to be notified by email about the main lottery (held in February).

Yes

No

Cancellations: I want to hear about follow-up lotteries with launch dates in: (select all months you are interested in)

January

April

July

October

February

May

August

November

March

June

September

December

River Trip Lottery Information

Date of most recent recreational Colorado river trip:

     

Select up to five launch date choices from available list of follow-up lottery launch dates:

For your launch date choices, list user names of potential alternate trip leaders:

[Enter launch dates]

[List user names]

Date

Potential Alternate Trip Leader

1st Choice

     

     

2nd Choice

     

     

3rd Choice

     

     

4th Choice

     

     

5th Choice

     

     

Qualified Boat Operator Information

Last Name

First Name

MI

Suffix

     

     

     

     

Street Address

     

City

State

Zip Code

Country

     

     

     

     

Date of Birth

Day Phone

Evening Phone

     

     

     

Email Address

     

Qualified boat-operator river experience

     

River Trip Participant Information (information required for each participant)

Last Name

First Name

MI

Suffix

     

     

     

     

Street Address

     

City

State

Zip Code

Country

     

     

     

     

Date of Birth

Day Phone

Evening Phone

     

     

     

Email Address

     

Date and location where participant will join the river trip

Date and location where participant will leave the river trip

     

     

River Trip Information

Date this trip passes Phantom Ranch

Date this trip passes or takes out at Diamond Creek

No. of participants launching from Lees Ferry     

     

     

     

Number of participants joining the trip after Lees Ferry but before Diamond Creek

Number of participants leaving the trip after Lees Ferry but before Diamond Creek

     

     

Number of participants joining the trip at Diamond Creek

Number of participants leaving the trip at Diamond Creek

     

     

Number of children age 15 and younger on the trip

Number of adults (age 16 and over) covered under this pass

Pass Serial Number(s)

River Trip Takeout Date

     

     

     

River Trip Takeout Location

River Trip Type

Diamond Creek Pearce Ferry South Cove

Motor Non-motor Non-motor support (hybrid)

By checking this box you agree to attend the Lees Ferry orientation program.

By checking this box you acknowledge that you read and understood the Grand Canyon National Park noncommercial river trip notice of penalties.

By checking this box you agree to the terms of the Grand Canyon National Park noncommercial use affidavit and certify that all of the information provided by you and members of your party is true and complete to the best of your knowledge.

CANYONLANDS NATIONAL PARK

River Trip Information

River Use Information

Please do not use this form for land-based trip reservations.

Cataract Canyon ($30 + 20 per person *)

Flat Water ($30 + 20 per person *)

Number of People*       Number of Boats (Describe in Section 5)       * In addition to the trip fees shown above, Canyonlands now charges $20 per person for all private River Use Permits. For example, a Cataract Canyon trip with five people now costs $30 (permit fee) + $100 (per person fee for five people), or $130.

Park Entry Point

Take-out Information

Mineral Bottom

Potash

Launch Date      

Location      

Date      

Upriver Shuttle?

Tag-A-Long Expeditions

Tex’s Riverways

Other Details

     

GLACIER BAY NATIONAL PARK AND PRESERVE
Dry Bay Arrival (Permit Date):	Planned Put-in Date:		Launch Location:
     	     		     
NOTE: If you are travelling through Kluane National Park and Reserve (Parks Canada) on the Upper Alsek, you must also have a put-in date/permit through Kluane NP&R. Please contact them at (867) 634-7207. I HAVE READ AND AGREE TO COMPLY WITH THE ALSEK RIVER PERMIT GUIDELINES
Would you like the above information shared with other boaters, including commercial companies, who might want to coordinate campsites/put-ins/shuttles? Yes No
How do you propose to handle a serious injury? (Remoteness should be given a strong consideration.)		     
E. Describe Spare Items: Repair kits and spare means of propulsion for watercraft.
     
A. Describe how garbage and dishwater will be disposed of and/or handled while on the trip. (A straining screen and “organics” container are recommended.)
     
B. Describe your human waste carryout system (brand or method). This is a mandatory requirement.
     
A. In the event that your party is in need of emergency assistance (medical evacuation, search and rescue, or emergency message), please describe in detail any information that would be helpful in locating your party from an aircraft. This includes colors and types of boats, rigging, tarps, tents, or other unusual equipment.
     
B. Describe your human waste carryout system (brand or method). This is a mandatory requirement.
     

ESTIMATED ITEMIZED EXPENSES
Please list the approximate expenses directly related to your river trip. Do not include expenses such as travel that would not be shared by all.
Food:		     
Rental Equipment:		     
List Equipment:	     
	     
	     
	     
	     
	     
	     
	     
	     
	     
	     
Rented From: (Name of equip. rental company)	     
Car Shuttle to Dalton Post or Haines Junction:		     
Arranged With: (Name of car shuttle company)	     
Air Taxi from Dry Bay:		     
Arranged With: (Name of air taxi company)	     
Other:	     	     
	     	     
	     	     
	     	     
	     	     
	     	     
	     	     
	     	     
	     	     
Total Cost to be Shared:		     
Number of Participants:		     

NONCOMMERCIAL USE AFFIDAVIT

(Glacier Bay National Park and Preserve)

Your signature as trip permittee on this affidavit indicates that you have considered the terms/conditions of the permit. You are aware of the penalties, should violations occur (see next page) and that your trip is organized and will be conducted in accordance with the provisions and requirements of a noncommercial river trip as specified below:

1. A noncommercial river trip must be participatory in nature. All members of the group must share trip preparation and conduct of the trip.

2. The purpose of the trip must be for its recreational values. The trip will not be conducted for the following reasons:

a) Monetary gain for any trip participant.

b) Acquisition of new equipment to the advantage of an individual, group, or organization.

c) Amortization of equipment.

3. Collecting a set fee (monetary compensation), payable to a trip participant, individual, group, or organization, for conducting, leading or guiding a noncommercial river trip is not allowed. The trip permittee should delegate responsibility (financial and otherwise) for various aspects of trip preparation and conduct.

4. Trips may be considered noncommercial even though a member of the trip receives a salary, under their normal scope of employment, from an educational institution or non-profit organization, but not directly through fees contributed by members of the party.

5. The use of advertising in any form or through any means in order to promote, foster or solicit participation in a noncommercial river trip is strictly prohibited.

6. The permittee must be present for the entire river trip. The permittee must be at least 18 years of age.

7. The approved permit is not transferable.

8. One non-commercial trip per year per person is allowed, so that others may enjoy the experience.

I have read and fully understand the requirements associated with the use of this noncommercial river permit and agree to assume full responsibility for the conduct of my entire party in obeying these rules and regulations. I am fully cognizant of the penalties involved should I and/or members of my party knowingly violate these rules and regulations. All application information is collected pursuant to guidelines established in 5 USC 552 A-E (1990).

By my signature I certify that all of the information provided by me and members of my party are true and complete to the best of my knowledge.

Applicant's Signature: Date:

NOTICE OF PENALTIES

(Glacier Bay National Park and Preserve)

As trip permittee you have the responsibility for ensuring this trip and all participants comply with the terms and conditions of the permit.

In the event that any violations of the permit, any and/or all trip members may be subject to the following legal and/or administrative penalties, depending on the nature of the violation.

A. A mandatory appearance before the U.S. Magistrate in Juneau or Anchorage, Alaska.

B. A fine of not more than $5,000 for each violation.

C. Imprisonment of not more than 6 months.

D. Forfeiture of gear and equipment used.

E. Revocation of an approved river trip permit and trip termination at any point within the park, including the removal of any and/or all trip members along with their equipment from Glacier Bay National Park and Preserve with all costs borne by the permittee and trip participants.

NOTICES

Notice Regarding the Use of Cell/Satellite Phones and Personal Locator Beacons

Communication devices may be helpful, but do not guarantee your safety or rescue. It is your responsibility to accept the risks inherent with your trip and to be self-reliant in the event of an emergency.

Privacy Act Statement

General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals completing this form.

Authority: 54 U.S.C. §100101, NPS Organic Act; 16 U.S.C. 1131-1136, Wilderness Act; 43 U.S.C. §1701 et seq., the Federal Land Policy and Management Act; 54 U.S.C. §200301-200310, Land and Water Conservation Fund Act, as amended; 16 U.S.C. §6801-6814, the Federal Lands Recreation Enhancement Act; 36 CFR Part 71, Recreation Fees; and, 36 CFR 1.6, Permits.

Purpose and Uses: To establish and verify an applicant's eligibility for a permit to conduct certain activities within the National Park System and to process permits for individual members of the public and organizations interested in obtaining a permit authorizing an activity. Information collected will be used to provide the public and permittees with permit-related information, to monitor activities conducted under a permit, to analyze data and produce reports to monitor the use park resources, to assess the impact of permitted activities on the conservation and management of protected species and their habitats, and to evaluate the effectiveness of the permit programs. The DOI and NPS may use the information to meet reporting requirements, to generate budget estimates and track performance, and to assist park staff with visitors’ education, fee collection, resource management and protection, recreational use planning, law enforcement and public safety personnel for such purposes as emergency contact and search and rescue efforts; to provide permit holders and participants with information about parks and their partners; and to provide reports of activities conducted under an issued permit.

Based on the disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, the National Park Service may share information with first responders and Federal, state, and local governments to provide information needed to locate an individual or render aid in an emergency; to recover debts owed to the United States; to respond to a violation or potential violation of the law; in response to a court order and/or discovery purposes related to litigation; or other authorized routine use when the disclosure is compatible with the purpose for which the records were compiled.

Effects of Nondisclosure: It is in your best interest to answer all of the questions. The U.S. Criminal Code, Title 18 U.S.C. 1001, provides that knowingly falsifying or concealing a material fact is a felony that may result in fines of up to $10,000 or 5 years in prison, or both. Deliberately and materially making false or fraudulent statements on this form will be grounds for not granting you a Backcountry/Wilderness Use Permit.

Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b): Your Social Security Number is not needed to complete this form.

Paperwork Reduction Act Statement

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) and 36 CFR 1-7, 12 and 13 which authorize the National Park Service to require applicants to fill out this form to monitor resources and to protect visitors. This information is being collected to allow the park management to make value judgements necessary to enhance the safety and enjoyment of both the visitors and wildlife. All applicable parts of the form must be completed in order for your request to be considered. You are not required to respond to this or any other Federal agency-sponsored information collection unless it displays a currently valid OMB control number.

Estimated Burden Statement

Public Reporting burden for this form is estimated to average 8 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, 12201 Sunrise Valley Dr. (MS-242), Reston, VA 20192. Do not send this application to this address but rather to the address at the top of the first page.

RECORDS RETENTION. TEMPORARY. Destroy 3 years after closure. (NPS Records Schedule, Protection and Safety (Item 2) Page 1 of 32

(N1-79-08-1))