Kelly Point Permit Application

NPS Form 10-404 (Rev. 08/2017)
National Park Service

OMB Control No. 1024-0022
Expiration Date 01/31/2024

Applicant Information

Last Name

First Name

Middle Initial

Suffix

Street Address

City

State

Zipcode

Country

Email Address

Next Step

Additional Contact Information

Home Phone #

Cell Phone #

Work Phone #

Fax #

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

Next Step

Submit Form

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.