Form 10-404 Backcountry/Wilderness Use Permit Application

NPS Form 10-404 (Rev. 06/2020) OMB Control No. 1024-0022

National Park Service Expiration Date XX/XX/XXXX

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 in the list or add any fields to the list. Changes or additions must be approved by OMB through the Bureau Information Collection Clearance Officer, Phadrea Ponds [970-267-7213].

APPLICANT INFORMATION (All Fields in this Section are Mandatory for Every Park)
When approved by NPS park official, this single-visit permit authorizes:
Last Name				First Name				Middle Initial
     				     				     
Street or Physical Address
     
City				State/Province		Postal Code		Country
     				     		     		     
NOTE TO PARKS: You may select from the menu of 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 or 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, Phadrea Ponds [970-267-7213].
MISCELLANEOUS INFORMATION
Contact Phone	Home Cell Work		Email Address
     			     
Date of Birth	Fax Number (Optional)		Driver’s License/Identification ##			Issuing State or Province		Issuing Country
     	     		     			     		USA Other
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/Girl Scouts, SUP, Church, Youth Camp, etc.)      					No. of Permits Requested (Large Groups, Multiple Leaders)      
Group Name				No. of Trips Requested			No. of People Per Trip
     				     			     
Commercial Guided Trip?			No. of People in Party		No. of Youth < Age {#}		No. of Adults > Age {#}
Yes No			     		     		     
Names of Group Members                                                                                  
Frequent Hiker Membership (Waives the $____ permit fee for ____ months from date of purchase)				I am already a member			No thanks
				Please enroll me for ____ years $____			Use hiker credit on file
Commercial Use Authorization (CUA) Permit #				Research Permit and Reporting System (RPRS) Permit #
     				     
Emergency Point-of-Contact Name		Family Friend Colleague		Emergency Point-of-Contact Phone Number			Emergency Point-of-Contact City/State/Province/Country
     				     			     
Will you bring a service dog? Yes No
Have you previously completed or received a mandatory permit orientation or briefing? Yes No If yes, when:      
Have you read and agree to all need to know information? Yes No

For the purposes of improving your visit, the NPS may seek to understand more about your experience. Are you willing to be

contacted by the NPS to participate in future visitor surveys and/or social science studies? Yes  No 

TYPE OF BACKCOUNTRY/WILDERNESS USE REQUESTED (Check All That Apply) ** Prohibited in Wilderness Areas (Exceptions may apply to previously established use of aircraft or motorboats pursuant to the Wilderness Act, Sec. 4(d)(1))

Camping

Backpacking

Mountaineering

Fishing

Hiking

Rafting

Mountain Climbing

Hunting

Canoeing

Packrafting

Rock Climbing

Motorboating **

Cross Country Skiing

Kayaking

Bouldering

Mountain Biking **

Snowshoeing

Sea Kayaking

Canyoneering

Snowmobiling **

Snowboarding

Drift boat floating

Scuba Diving

ATVOHV Use **

Pack and Saddle Stock Use

Dog Mushing/Sledding

Sail boating

Other

MODE OF TRANSPORTATION Filed marked with ** are prohibited in Wilderness Areas (Exceptions may apply to previously established use of aircraft or motorboats pursuant to the Wilderness Act, Sec. 4(d)(1))

Motor Vehicle(s) (Including ORVs and Motorcycles) **

Snowmobile(s) **

State/Province      

Registration/Plate #      

State/Province      

Registration/Plate #      

Make

     

Model

     

Make

     

Model

     

Color

     

Rental?

Yes No

Color

     

Rental

Yes No

Parking Location      

Parking Location      

Aircraft **

Watercraft

Registration N-Number       Make       Model       Number       Color       Landing Area (Drop Off)       Landing Area (Pick Up)       Commercial Air Taxi Yes No Name of Company      

Types: Canoe(s), kayak(s), raft(s), packraft(s), drift boat(s), motorized vessel(s), sailboat(s), other: Type       Number       Make       Model       Colors       Length       Horsepower       ** State/Province       Hull Registration #       Launch Location       Launch Date       Take Out Location       Take Out Date       Trailer Parking Location       Rental Yes No

EQUIPMENT (Check All That Apply & Indicate Quantity Where Appropriate) Fields marked with * are referenced in the Special Notices Section Fields marked with ** are prohibited in Wilderness Areas

Approved Bear Resistant Food Storage Container(s)

Bear Spray

Electric Bear Fence

Avalanche Transceiver(s)

Avalanche Shovel(s)

Avalanche Probe Pole(s)

Camp Stove(s)

Climbing Helmet(s)

Climbing Rope(s) (length      )

Compass

GPS Device(s)

Maps

Human Waste Disposal/Pack Out System(s)

Whistle

Headlamp/Flashlight

Skis

Snowshoes

Snowboard(s)

Supplemental Oxygen

Fire Starter

Extra paddle or oar

Water Purification Device/System(s)

Ice Axes(s)

Other (specify)      

Climbing Hardware (list here)      

	Cellular Telephone(s) * (include type, service provider, phone # and quantity)	Type(s)      		Service Provider(s) & Phone #(s)      
	Satellite Telephone(s) * (include type, service provider, phone # and quantity)	Type(s)      		Service Provider(s) & Phone #(s)      
	Personal Locator Beacon(s) or Device(s) * (include type and service provider)	Type(s)      		Service Provider(s) & Phone #(s)      
	Radio(s) *	Type(s)      
	Emergency signaling devices	Type			Quantity
		U.S. Air Force type signal mirror			     
		Signal panel			     
		Signal flare			     
		Signal strobe			     
		Other (list):      			     
	Tent or Shelter (Including hammock)	Type(s)	Color(s)		Quantity
		     	     		     
	Bicycle or Mountain Bike**	Type(s)	Color(s)		Quantity
		     	     		     
	Snow Sled/Sledge	Type(s)	Color(s)		Quantity
		     	     		     
	Pack & Saddle Stock	Type(s)			Quantity
		     			     
	First Aid Kits		Type		Quantity
			Minor		     
			Major		     
U.S. Coast Guard Approved Personal Flotation Devices					Quantity
	Offshore Lifejacket - Type 1				     
	Near Shore Buoyant Vest - Type II				     
	Flotation Aid - Type III				     
	Throwable Device - Type IV (boat cushions, ring buoys, horseshoe buoys, throw bags, and throw lines)				     
	Special Use Device - Type V (includes include work vests, deck suits, and hybrids for restricted use				     
	Inflatable Life Jackets				     
	Backpack		Type(s)		Color(s)
			     		     
	Footwear		Type(s)		Size(s)
			     		     
	Dog Team/Sled(s)		# of Sleds		# of Dogs
			     		     

ITINERARY DETAILS

Start Date

End Date

Entry Location

Exit Location

     

     

     

     

Night

Date

Campsite /Camp Location /Use Area/Trail or Route

Night 1

     

     

Night 2

     

     

Night 3

     

     

Night 4

     

     

Night 5

     

     

Night 6

     

     

Night 7

     

     

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      

     

     

PERMIT FEE PAYMENT INFORMATION

Name on Card

Billing Phone Number

     

     

Billing Address

City

State/Province

Postal Code

Country

     

     

     

     

     

Method of Payment Check Money Order MasterCard Visa Discover American Express

Fee Discounts: Interagency Access Pass Interagency Annual Senior Pass Interagency Lifetime Senior Pass Golden Access Pass Golden Age Pass

Credit Card Number

Expiration Date

CVC Code #

Total Amount Authorized

     

     

     

$      

Signature

Date

     

     

MISCELLANEOUS

Special Notice **

Notice Regarding the Use of Cell Phones, Satellite Phones, and Personal Locator Devices 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.

Remarks

     

Special Instructions

     

SIGNATURES

Visitor’s Signature

Date

Issuing Officer’s Signature

Date/Time

     

     

     

     

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

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

CANYONLANDS NATIONAL PARK
River Trip Information
River Use Information
Please do not use this form for land-based trip reservations.
Cataract Canyon				Flat Water
Number of People *       Number of Boats Vessels (Describe in Other Details)      
Park Entry Point					Take-out Information
Mineral Bottom		Potash	Launch Date      		Location      		Date      
					Upriver Shuttle Company (if using one):      
Other Details
     
GREAT SMOKY MOUNTAINS 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)
						          

GRAND CANYON NATIONAL PARK
Permit Number (issued by Park)							Permit request ID (issued by Park)
Please provide desert and/or Grand Canyon hiking experience.
     
Daily Itinerary Details (use additional pages if necessary)
	Date	Daily Mileage (very important)			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

Grand Canyon National Park continued - 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 with 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.
Family Member Potential Alternate Trip Leader Information
Is the proposed PATL an immediate family member? (legal spouses, children, parents, and siblings as well as legal spouses of these children, parents, and siblings) Yes No
Will the proposed PATL be 18 or older on the launch date? Yes No
Did the proposed PATL apply in the same lottery? (as either a trip leader or a confirmed PATL) Yes No
Is the proposed PATL already on a recreational river trip the same year as this launch date? Yes No
Would adding this proposed PATL cause lottery application points to decrease? Yes No
Proposed PATL last recreational river trip date:      
Proposed PATL last won river trip date:      
Proposed PATL Legal Name:      
Proposed PATL User Name (from their river profile):      

YELLOWSTONE NATIONAL PARK

APPLICANT INFORMATION

(Backcountry Permit Application)

Additional Party Members Names:

METHOD OF TRAVEL (Check All That Apply)

I will use the Yellowstone Lake boat shuttle: Yes  No 

I am camping at a Yellowstone Lake Dock Site: On my boat? Yes   No  On shore? Yes  No 

YOSEMITE NATIONAL PARK
First Nights Camp Location.      
Own Canister
Bear Lockers (HSC/LYV Only)
Rented Canister (Include canister numbers)
Make/Model of Bear Canister(s).      
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 $10.00 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
Will the trail you are traveling on exit Yosemite National Park and enter a different wilderness area? Yes No
Please specify which mountain pass you plan to hike over when exiting Yosemite.      
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

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.,16 U.S.C. §6801-6814, the Federal Lands Recreation Enhancement Act; 36 CFR Part 71, Recreation Fees; 36 CFR 1.6, Permits; and 36 CFR 2.23 Recreation Fees.

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 visitor 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.

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, 1201 Oakridge Drive, Fort Collins, CO 80525. Do not send this application to this address but rather to the park address listed at the top of the first page.

 

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