Form 10-404AK Alaska Backcountry/Wilderness Use Permit

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

National Park Service Expiration Date XX/XX/XXXX

ALASKA BACKCOUNTRY/WILDERNESS USE PERMIT APPLICATION

[Applicable only in Denali National Park and Preserve (former Mount McKinley National Park and Kantishna area pursuant to 36 CFR 13.904) and Glacier Bay National Park and Preserve (Alsek Corridor pursuant to 36 CFR 1108 and Glacier Bay proper pursuant to 36 CFR 13.1108)]

[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                                                                                  
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:      
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)

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

Other

MODE OF TRANSPORTATION

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), pack raft(s), drift boat(s), motorized vessel(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 an * are referenced in the Special Notices section

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      	     			     
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

[NAME OF PARK HERE]
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 CAMPING 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.)		     
A. Describe Spare Items: Repair kits and spare means of propulsion for watercraft.
     
B. Describe how garbage and dishwater will be disposed of and/or handled while on the trip. (A straining screen and “organics” container are recommended.)
     
C. Describe your human waste carryout system (brand or method). This is a mandatory requirement.
     
D. 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.
     

GLACIER BAY NP&P CONTINUED - ESTIMATED ITEMIZED EXPENSES
Please list the approximate expenses directly related to your river camping 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 - ONLY)

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 camping trip as specified below:

1. A noncommercial river camping 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 camping 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 camping trip is strictly prohibited.

6. The permittee must be present for the entire river camping 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 camping trip 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 - ONLY)

As river camping 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 camping 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.

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. National Park Service Backcountry/Wilderness Use Permit requirements must be based on regulations established in 36 CFR §1.6 and §2.10 (outside of Alaska) and in 36 CFR, Part 13 (in Alaska). Prohibited in Wilderness with the following exceptions: 1) Wilderness areas located in National Park Service units in Alaska, pursuant to PL. 96-487, Alaska National Interest Lands Conservation Act (a) and 43 CFR §36.11 - Special Access; 2) Wilderness area in National Park Service units outside of Alaska where use of aircraft or motorboats have already become established, pursuant to the Wilderness Act §4(d)(1).

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. Please send to the park address at the top of the first page.

 

RECORDS RETENTION. TEMPORARY. Destroy 3 years after closure. (NPS Records Schedule, Protection and Safety (N1-79-08-1))

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