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pdfNPS Form 10-404AK (Rev. 06/2020)
National Park Service
0MB Control No. l024-0022
Expiration Date xx/xx/20xx
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 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 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 which is 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].
Contact Phone
Date of Birth
□
□
□
MISCELLANEOUS INFORMATION
Home
Cell
Work
Fax
Email Address
Driver's License/Identification##
□
Issuing State or Province
Issuing Country
USA
Other
No Do you have an lnteragency Access or Senior Pass? D Yes
If "Yes", pass#:
□
□
Do you have an America the Beautiful Pass?
Yes D
If "Yes", pass#:
Group/Organization Type (Boy/Girl Scouts, SUP, Church,
No. of Permits Requested (Large Groups, Multiple Leaders)
Youth Camp, etc.)
No. of People Per Trip
Group Name
No. of Trips Requested
Commercial Guided Trip?
Yes D No
No. of People in Party
□
No. of Youth < Age {
}
No. of Adults > Age {
}
Names of Group Members
Commercial Use Authorization (CUA) Permit#
Emergency Point-of-Contact
Name
Will you bring a service dog?
□
□
□
Family
Friend
Colleague
Research Permit and Reporting System (RPRS) Permit#
Emergency Point-of-Contact
Phone Number
Emergency Point-of-Contact
City/State/Province/Country
D Yes D No
Have you previously completed or received a mandatory permit orientation or briefing?
Page 1 of 8
D Yes D No
If yes, when:
□ No
0MB Control No. l024-0022
Expiration Date xx/xx/20xx
NPS Form 10-404AK (Rev. 06/2020)
National Park Service
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
D
No
D
TYPE OF BACKCOUNTRY/WILDERNESS USE REQUESTED
(Check All That Apply)
□
□
□
□
□
□
□
Camping
Hiking
Canoeing
Cross Country Skiing
Snowshoeing
Snowboarding
Pack and Saddle Stock Use
□
□
□
□
□
□
□
Backpacking
Rafting
Packrafting
Kayaking
Sea Kayaking
Drift boat floating
Dog Mushing/Sledding
□
□
□
□
□
□
□
□ Fishing
□ Hunting
□ Motorboating
□ Mountain Biking
□ Snowmobiling
□ ATVOHV Use
Mountaineering
Mountain Climbing
Rock Climbing
Bouldering
Canyoneering
Scuba Diving
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?
Color
Rental
□ Yes □ No
□ Yes □ No
Parking Location
Parking Location
Aircraft
Watercraft
Registration N-Number
Types: Canoe(s), kayak(s), raft(s), pack raft(s), drift boat(s),
motorized vessel(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
Colors
Hull Registration#
Launch Location
Launch Date
Take Out Location
Take Out Date
Trailer Parking Location
Rental
□
□
□
□
□
□
□
□
□
D 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)
Avalanche Transceiver(s)
Camp Stove(s)
Compass
Human Waste Disposal/Pack Out System(s)
Skis
Supplemental Oxygen
Water Purification Device/System(s)
□
□
□
□
□
□
□
□
Bear Spray
Avalanche Shovel(s)
Climbing Helmet(s)
GPS Device(s)
Whistle
Snowshoes
Fire Starter
Ice Axes(s)
Climbing Hardware (list here)
Page 2 of 8
□
□
□
□
□
□
□
□
Electric Bear Fence
Avalanche Probe Pole(s)
Climbing Rope(s) (length
Maps
Headlamp/Flashlight
Snowboard(s)
Extra paddle or oar
Other (specify)
)
0MB Control No. l024-0022
Expiration Date xx/xx/20xx
NPS Form 10-404AK (Rev. 06/2020)
National Park Service
Cellular Telephone(s) *
Type(s)
Service Provider(s) & Phone#(s)
Type(s)
Service Provider(s) & Phone#(s)
Type(s)
Service Provider(s) & Phone#(s)
(include type, service provider, phone# and quantity)
Satellite Telephone(s) *
(include type, service provider, phone# and quantity)
Personal Locator Beacon(s) or Device(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
□
□
Other (list):
Tent or Shelter
Bicycle or Mountain Bike
□
Snow Sled/Sledge
□
Pack & Saddle Stock
□
Type(s)
Color(s)
Quantity
Type(s)
Color(s)
Quantity
Type(s)
Color(s)
Quantity
(Including hammock)
Type(s)
□
□
First Aid Kits
U.S. Coast Guard Approved Personal Flotation Devices
□
□
□
□
□
□
□
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)
Page 3 of 8
Type(s)
Color(s)
Type(s)
Size(s)
# of Sleds
# of Dogs
0MB Control No. l024-0022
Expiration Date xx/xx/20xx
NPS Form 10-404AK (Rev. 06/2020)
National Park Service
ITINERARY DETAILS
Start Date
Entry Location
End Date
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:
Group Size
Trip Length (# of nights)
# of Campsites
Minimum Group Size
Flexible Itinerary?
No
Yes
□
□
D Similar/Nearby Campsites
D Reverse Itinerary
□ Alternate Dates
Earliest Start Date
Latest Start Date
to
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
Visitor's Signature
Date
SIGNATURES
Issuing Officer's Signature
Page 4 of 8
Date/Time
0MB Control No. l024-0022
Expiration Date xx/xx/20xx
NPS Form 10-404AK (Rev. 06/2020)
National Park Service
{NAME OF PARK HEREl
Dry Bay Arrival (Permit Date):
Planned Put-in Date:
Launch Location:
NOTE: [Enter park notices here]
I HAVE READ AND AGREE TO COMPLY WITH THE {ENTER PARK SITE! CAMPING PERMIT GUIDELINES
Would you like the above information shared with other boaters, including commercial companies, who might want to coordinate campsites/putins/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.
Page 5 of 8
0MB Control No. l024-0022
Expiration Date xx/xx/20xx
NPS Form 10-404AK (Rev. 06/2020)
National Park Service
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 bv all.
Food:
Rental Equipment:
List Equipment:
Rented From:
(Name of equip. rental company)
Car Shuttle to [enter park sites here]:
Arranged With:
(Name of car shuttle company)
Air Taxi from [enter park sites here]:
Arranged With:
(Name of air taxi company)
Other:
-
Total Cost to be Shared:
Number of Participants:
Page 6 of 8
NPS Form 10-404AK (Rev. 06/2020)
National Park Service
0MB Control No. l024-0022
Expiration Date xx/xx/20xx
NONCOMMERCIAL USE AFFIDAVIT
(Update as needed to include park-specific information)
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 1 8 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 (1 990).
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.
Date:
Applicant's Signature:
NOTICE OF PENALTIES
(Update as needed to include park-specific information)
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 [ENTER PARK SITE HERE] with all costs borne by the permittee and trip
participants.
Page 7 of 8
NPS Form 10-404AK (Rev. 06/2020)
National Park Service
0MB Control No. l024-0022
Expiration Date xx/xx/20xx
NOTICES
Privacy Act Statement
General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1 974), December 2 1 , 1 984, for individuals completing
this form.
Authority: 54 U. S. C. §1 001 01 , NPS Organic Act; 1 6 U. S.C. 1 1 3 1 -1 1 36, Wilderness Act; 43 U. S. C. §1 701 et seq., 1 6 U. S. C. §6801 681 4, the Federal Lands Recreation Enhancement Act; 36 CFR Part 7 1 , 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. 1 0 (outside of Alaska) and in 36 CFR, Part 1 3 (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. 1 1 - 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 1 8 U. S. C. 1 001 ,
provides that knowingly falsifying or concealing a material fact is a felony that may result in fines of up to $1 0, 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, 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 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 0MB 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 20192. Do not send this application to this address. Please send to the Park address on the first page.
Page 8 of 8
| File Type | application/pdf |
| File Title | 10-404AK |
| Author | dhaas |
| File Modified | 2023-06-23 |
| File Created | 2021-07-27 |