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pdf0MB Control No. 1024-0022
Expiration Date XX/XX/20XX
NPS Form 10-404 (Rev. 06/2020)
National Park Service
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 0MB 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 annroved bv NPS park official this sinale-visit permit authorizes:
Last Name
First Name
Middle Initial
Street or Physical Address
City
State/Province
Country
Postal Code
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 0MB
through the Bureau Information Collection Clearance Officer, Phadrea Ponds [970-267-7213].
MISCELLANEOUS INFORMATION
Contact Phone
Date of Birth
Home
Cell
Work
Fax
Email Address
Driver's License/Identification##
Issuing State or Province
Issuing Country
USA
Other
Yes
No Do you have an lnteragency Access or Senior Pass?
If "Yes", pass#:
Yes
Do you have an America the Beautiful Pass?
If "Yes", pass#:
Group/Organization Type (Boy/Girl Scouts, SUP, Church,
No. of Permits Requested (Large Groups, Multiple Leaders)
Youth Camp, etc.)
Group Name
No. of Trips Requested
No. of People Per Trip
Commercial Guided Trip?
Yes
No
No. of People in Party
No. of Youth < Age{#}
No. of Adults > Age{#}
Names of Group Members
Frequent Hiker Membership
(Waives the $_ _ permit fee for
__ months from date of purchase)
Commercial Use Authorization (CUA) Permit#
Use hiker credit on file
$
Research Permit and Reporting System (RPRS) Permit #
Emergency Point-of-Contact
Name
Emergency Point-of-Contact
Phone Number
Will you bring a service dog?
Family
Friend
Colleague
Yes
I am already a member
Please enroll me for _
_
No thanks
years
Emergency Point-of-Contact
City/State/Provi nee/Country
No
Have you previously completed or received a mandatory permit orientation or briefing?
Have you read and agree to all need to know information?
Yes
Yes
No If yes, when
No
RECORDS RETENTION. TEMPORARY. Destroy 3 years after closure. (NPS Records Schedule, Protection and Safety (N1-79-08-1))
Page 1 of 9
No
NPS Form 10-404 (Rev. 06/2020)
National Park Service
0MB Control No. 1024-0022
Expiration Date XX/XX/20XX
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?
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Yes
D
No
D
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
Hiking
Canoeing
Cross Country Skiing
Snowshoeing
Snowboarding
Pack and Saddle Stock Use
□
□
□
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Backpacking
Rafting
Packrafting
Kayaking
Sea Kayaking
Drift boat floating
Dog Mushing/Sledding
□
□
□
□
□
□
□
□ Fishing
□ Hunting
□ Motorboating**
□ Mountain Biking**
□ Snowmobiling**
□ ATVOHV Use**
□ Other
Mountaineering
Mountain Climbing
Rock Climbing
Bouldering
Canyoneering
Scuba Diving
Sail boating
MODE OF TRANSPORTATION
Filed marked with ** are prohibited in Wilderness Areas
(Exceotions mav aoolv to oreviouslv established use of aircraft or motorboats oursuant to the Wilderness Act, Sec. 4(d)(1))
Snowmobile(s)**
Motor Vehicle(s) (Including ORVs and Motorcycles)**
State/Province
Registration/Plate#
State/Province
Registration/Plate#
Make
Model
Make
Model
Color
Rental?
Color
Rental
□ Yes □ No
□ Yes □ No
Parking Location
Parking Location
Aircraft**
Watercraft
Registration N-Number
Types: Canoe(s), kayak(s), raft(s), packraft(s), drift boat(s), motorized
vessel(s), sailboat(s), other:
Make
Model
Number
Color
Landing Area (Drop Off)
Landing Area (Pick Up)
Commercial Air Taxi
Name of Company
□ Yes □ No
Type
Number
Make
Model
Length
Horsepower
State/Province
**
Hull Registration#
Launch Location
Launch Date
Take Out Location
Take Out Date
Trailer Parking Location
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Colors
Rental
D Yes
EQUIPMENT(Check All That Apply & Indicate Quantity Where Appropriate)
Fields marked with * are referenced in the Special Notices Section
Fields marked with ** are orohibited in Wilderness Areas
Approved Bear Resistant Food Storage Container(s)
Avalanche Transceiver(s)
Camp Stove(s)
Compass
Human Waste Disposal/Pack Out System(s)
Skis
Supplemental Oxygen
Water Purification Device/System(s)
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Bear Spray
Avalanche Shovel(s)
Climbing Helmet(s)
GPS Device(s)
Whistle
Snowshoes
Fire Starter
Ice Axes(s)
□
□
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□
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□
□ No
Electric Bear Fence
Avalanche Probe Pole(s)
Climbing Rope(s) (length
Maps
Headlamp/Flashlight
Snowboard(s)
Extra paddle or oar
Other (specify)
Climbing Hardware (list here)
RECORDS RETENTION. TEMPORARY. Destroy 3 years after closure. (NPS Records Schedule, Protection and Safety (N1-79-08-1))
Page 2 of 9
)
NPS Form 10-404 (Rev. 06/2020)
National Park Service
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(include type, service provider, phone# and quantity)
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(include type, service provider, phone# and quantity)
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Cellular Telephone(s) *
Satellite Telephone(s) *
Personal Locator Beacon(s) or Device(s) *
0MB Control No. 1024-0022
Expiration Date XX/XX/20XX
Type(s)
Service Provider(s) & Phone#(s)
Type(s)
Service Provider(s) & Phone#(s)
Type(s)
Service Provider(s) & Phone#(s)
(include type and service provider)
Radio(s) *
Type(s)
Type
□
Quantity
U.S. Air Force type signal mirror
Emergency signaling devices
Signal panel
Signal flare
Signal strobe
□
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Other (list):
Tent or Shelter
Color(s)
Quantity
Type(s)
Color(s)
Quantity
Type(s)
Color(s)
Quantity
(Including hammock)
Bicycle or Mountain Bike**
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Snow Sled/Sledge
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Pack & Saddle Stock
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Type(s)
Type(s)
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First Aid Kits
U.S. Coast Guard Approved Personal F lotation Devices
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Quantity
Type
Quantity
Minor
Major
Quantity
Offshore Lifejacket - Type 1
Near Shore Buoyant Vest - Type II
Flotation Aid - Type Ill
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
□
Footwear
□
Dog Team/Sled(s)
Type(s)
Color(s)
Type(s)
Size(s)
# of Sleds
# of Dogs
RECORDS RETENTION. TEMPORARY. Destroy 3 years after closure. (NPS Records Schedule, Protection and Safety (N1-79-08-1))
Page 3 of 9
NPS Form 10-404 (Rev. 06/2020)
National Park Service
0MB Control No. 1024-0022
Expiration Date XX/XX/20XX
ITINERARY DETAILS
Start Date
Entry Location
End Date
Exit Location
Night
Campsite / Camp Location / Use Area/Trail or Route
Date
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:
Trip Length (# of nights)
Group Size
# of Campsites
Minimum Group Size
Flexible Itinerary?
No
Yes
Alternate Dates
to
Similar/Nearby Campsites
Reverse Itinerary
Earliest Start Date
Latest Start Date
PERMIT F EE PAYMENT INF ORMATION
Name on Card
Billing Phone Number
City
Billing Address
Method of Payment
Check
Money Order
Fee Discounts:
lnteragency Access Pass
Golden Age Pass
Golden Access Pass
Credit Card Number
State/ Province
MasterCard
Visa
lnteragency Annual Senior Pass
Expiration Date
Postal Code
Country
Discover
American Express
lnteragency Lifetime Senior Pass
eve Code#
Total Amount Authorized
$
Date
Signature
MISCELLANEOUS
Notice Regarding the Use of Cell Phones, Satellite Phones, and Personal Locator Devices
Special Notice**
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
RECORDS RETENTION. TEMPORARY. Destroy 3 years after closure. (NPS Records Schedule, Protection and Safety (N1-79-08-1))
Page 4 of 9
NPS Form 10-404 (Rev. 06/2020)
National Park Service
0MB Control No. 1024-0022
Expiration Date XX/XX/20XX
(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
Number of People *
Flat Water
Number of Vessels (Describe in Other Details)
Take-out Information
Park Entrv Point
Mineral Bottom
Potash
Date
Location
Launch Date
Upriver Shuttle Company (if using one):
Other Details
GREAT SMOKY MOUNTAINS NATIONAL PARK
Annalachian Trail Thru-Hiker Backcountrv 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:
Southbound
Northbound
Estimated date you will begin your hike through
(Specify Date)
National Park.
GRAND CANYON NATIONAL PARK
Permit Number (issued by Park)
Please provide desert and/or Grand Canyon hiking experience.
Permit request ID (issued by Park)
Daily Itinerary Details
Date
(use additional paqes if necessary)
Daily Mileage
(very important)
Camp Location I Use Area
Night 1
Night 2
Night 3
Night 4
Night 5
Night 6
Night 7
River Trip Leader Information
Date of most recent recreational
Colorado River trip
(Permit Applicant)
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).
Cancellations: I want to hear about follow-up lotteries with launch dates in: (select all months you are interested in)
January
February
March
April
May
June
July
August
September
Yes
No
October
November
December
RECORDS RETENTION. TEMPORARY. Destroy 3 years after closure. (NPS Records Schedule, Protection and Safety (N1-79-08-1))
Page 5 of 9
NPS Form 10-404 (Rev. 06/2020)
National Park Service
0MB Control No. 1024-0022
Expiration Date XX/XX/20XX
Grand Canyon National Park continued - River Trip Lottery Inf ormation
Date of most recent recreational Colorado river
trip:
Select up to five launch date choices from
available list of follow-up lottery launch dates:
Enter launch dates
Date
1st Choice
2 nd Choice
3 rd Choice
4th Choice
5th Choice
For your launch date choices, list user names of potential alternate trip leaders:
List user names
Potential Alternate Trip Leader
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I
Qualif ied Boat Operator Inf ormation
Last Name
Street Address
Ml
First Name
City
State
Date of Birth
Suffix
Country
Zip Code
Evening Phone
Day Phone
Email Address
Qualified boat-operator river experience
River Trip Participant Information
(information required for each participant)
First Name
Last Name
Ml
Street Address
City
State
Date of Birth
Day Phone
Zip Code
I
Suffix
Country
Evening Phone
Email Address
Date and location where participant will join the river trip
Date this trip passes Phantom
Ranch
Date and location where participant will leave the river trip
River Trip Information
Date this trip passes or takes out at
No. of participants launching from Lees Ferry
Diamond Creek
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
RECORDS RETENTION. TEMPORARY. Destroy 3 years after closure. (NPS Records Schedule, Protection and Safety (N1-79-08-1))
Page 6 of 9
NPS Form 10-404 (Rev. 06/2020)
National Park Service
0MB Control No. 1024-0022
Expiration Date XX/XX/20XX
River Trip Takeout Location
River Trip Type
D Diamond Creek D Pearce Ferry D South Cove
D Motor
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□
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Non-motor
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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 knowledqe.
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 D No
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Will the proposed PATL be 18 or older on the launch date? Yes D
No
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Did the proposed PATL apply in the same lottery? (as either a trip leader or a confirmed PATL) Yes
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Is the proposed PATL already on a recreational river trip the same year as this launch date? Yes D
Would adding this proposed PATL cause lottery application points to decrease? Yes D
No
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No
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 D No
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I am camping at a Yellowstone Lake Dock Site: On my boat? Yes D No
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On shore? Yes D No
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YOSEMITE NATIONAL PARK
First Nights Camp Location.
I
I
I
I
D Own Canister
□ Bear Lockers (HSC/LYV Only)
D 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
No
additional $10.00 per person, payable when I pick up my wilderness permit. (Check) D Yes
If Half Dome permits are NOT
available for my trip (check):
□
□
□
Please do NOT process this reservation
I
Number of Permits
Make this wilderness permit reservation without Half Dome permits. I understand that there are no refunds
for wilderness permit reservations
RECORDS RETENTION. TEMPORARY. Destroy 3 years after closure. (NPS Records Schedule, Protection and Safety (N1-79-08-1))
Page 7 of 9
NPS Form 10-404 (Rev. 06/2020)
National Park Service
0MB Control No. 1024-0022
Expiration Date XX/XX/20XX
Half Dome Lottery
Group Leader Information
Date of Birth
Group Leader
Alternate Group Leader Information
Date of Birth
Group Leader
Applying For
Permit Type
Facility
Entrance
Preferred Choice
Permit Entry Date
Alternative Choice 1
Permit Group Size
Donohue Pass
I would like to exit over Donohue Pass on this overniaht wilderness trio.
Yes
If the Donohue Pass Exit quota is NOT
available for my trip (check):
Permit Group Size
Permit Entry Date
No
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):
Date
Trip leader's signature
RECORDS RETENTION. TEMPORARY. Destroy 3 years after closure. (NPS Records Schedule, Protection and Safety (N1-79-08-1))
Page 8 of 9
NPS Form 10-404 (Rev. 06/2020)
National Park Service
0MB Control No. 1024-0022
Expiration Date XX/XX/20XX
Privacy Act Statement
General: This information is provided pursuant to Public Law 93-579 ( Privacy Act of 1 9 74), December 2 1 , 1 984, for individuals
completing this form.
Authority: 54 U.S.C. § 1 00 1 0 1 , N PS Organic Act; 1 6 U.S.C. 1 1 3 1 - 1 1 36, Wilderness Act; 43 U.S.C. § 1 70 1 et seq., 1 6 U.S.C. §680 1 68 1 4, the Federal Lands Recreation Enhancement Act; 36 C F R Part 7 1 , Recreation Fees; 36 C F R 1.6, Permits; and 36 C F R 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 D OI and N PS may use the information to meet reporting re quirements, 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. 1 00 1,
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. 350 1 ) and 36 C F R 1 -7, 1 2 and 1 3 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 re quest to be considered. You are not re quired to
respond to this or any other Federal agency-sponsored information collection unless it displays a currently valid 0M B 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 Drive
(MS-242) Reston, VA 2019 2. Do not send your completed form to this address. Please send to the Park address on teh first page.
RECORDS RETENTION. TEMPORARY. Destroy 3 years after closure. (NPS Records Schedule, Protection and Safety (N1-79-08-1))
Page 9 of 9
| File Type | application/pdf |
| File Title | NPS Form 10-404 |
| Author | dhaas |
| File Modified | 2023-06-23 |
| File Created | 2021-07-15 |