Wilderness Permit Application Form

Name:__________________________

Address:________________________

City, State:___________________________

Zip Code:___________________________

Daytime Phone Including Area Code:

________________________________

Organization or Group Name:

________________________________

Wilderness Area:

________________________________

Destination (day trip only):

________________________________

Alternate Choice

Trailhead/entry date:____________________________

Trailhead/exit date:____________________________

Second Alternate Choice

Trailhead/entry date________________

Trailhead/exit date_________________

Vehicle License Plate # _________________

Vehicle Description (Make, Model, Color)_____________

__________________________________________________

Emergency Contact (Name and Phone) ______________

__________________________________________________

_______________________________

Finish Date:

_______________________________

Entry Trailhead:

_______________________________

Exit Trailhead:

_______________________________

Primary Travel Method (circle one):

Walking

Saddle Stock

Walking With Stock

Number of Persons in Party:

_______________________________

Number and type of pack/saddle stock:

_______________________________

Stock Type (circle one):

Private

Commercial

Itinerary

Number Of Nights

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

For additional itinerary please attach an additional sheet.

I agree to abide by all laws, rules, and regulations which apply to this wilderness area. I will do my best to see that everyone in my party does likewise.

Applicant Signature _____________________________

Date_______________