Fillable Backcountry Permit Request (National Park Service)

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Backcountry Permit Request (National Park Service)

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National Park Service
U.S. Department of the Interior
Grand Canyon National Park
Backcountry Information Center
(928) 638-7875 phone
(928) 638-2125 fax
www.nps.gov/grca
grca_bic@nps.gov
Backcountry Permit Request
Things to Know Before Applying
When to Apply. To give your request the best chance, submit it by 5pm MST on the 1st of the month
that is four months prior to the proposed start date. (Note: you can submit it up to 10 days earlier, but
these earlier requests will be treated as if they arrived on the 1st and placed in a computer generated
random order once duplicates have been removed.) It may take Rangers up to three weeks to process all
Earliest Consideration requests. Once this is completed all later requests are considered in the order
received.
How to Apply. PERMIT REQUESTS ARE NOT ACCEPTED BY TELEPHONE OR EMAIL.
• Fax request to the Backcountry Information Center, 928-638-2125.
• Mail request to Grand Canyon Permits Office, 1824 S Thompson Street, #201, Flagstaff AZ, 86001.
• Bring request to the Backcountry Information Center, located inside the park on both the South
Rim and the North Rim.
Permit Response. Please allow up to three weeks for your backcountry permit request to be processed.
Requests are responded to via U.S. Mail or email.
Safety. Travel in Grand Canyon National Park backcountry has inherent risks and hikers assume
complete responsibility for their own safety. Rescue is not a certainty. Backcountry users should be in
good physical condition and should be able to survive on their own by taking the necessary precautions
and equipment. Your safety is your responsibility. Visit www.nps.gov/grca/planyourvisit/hike-tips.htm for
more information.
Regulations. Grand Canyon hikers are responsible for knowing and obeying all backcountry rules and
regulations. Visit www.nps.gov/grca/planyourvisit/backcountry-regs.htm for more information.
Multiple Permits. In order to safeguard the highest quality backcountry experience for all hikers,
regulations stipulate that all permits are void when a group (i.e. same club, organization, group of
friends, etc.) obtains multiple permits for the same campground or use area for the same night.
Itinerary. You may submit as many itinerary choices as you wish (use additional pages if necessary, be
sure to include your full name on all additional pages). Itineraries can be longer than seven nights. To
ensure a backcountry permit reflects your request, dates must be consecutive within itinerary. Include
nights at Phantom Ranch, on Forest Service land, and on Tribal land.
Group Size. More permits are available for small groups (1-6 people) than for large groups (7-11
people). Because there are only a few large group sites, limiting the size of your group will increase your
chances of obtaining a permit.
Permit Cost. $10 per permit plus $8 per person or stock animal per night camped below the rim and $8
per group per night camped above the rim. Denied requests will not incur a charge. Permits cancelled at
least four days in advance will receive hiker credit (minus a $10 cancellation charge) valid for one year.
Backcountry Information Center charges are NON-REFUNDABLE!
For more information including seasonal hiking tips, trail information, Leave No Trace, Hike Smart, and
private stock requirements visit www.nps.gov/grca/planyourvisit/backcountry.htm
NPS Form 10-404 (Rev. 04/2017)
National Park Service
OMB Control No. 1024-0022
Expiration Date 08/31/2020
BACKCOUNTRY/WILDERNESS USE PERMIT APPLICATION
Grand Canyon National Park
Backcountry Information Center
1824 S Thompson St, Suite 201
Flagstaff, AZ 86001
Telephone (928) 638-7875, FAX (928) 638-2125
APPLICANT INFORMATION
Last Name First Name MI Suffix
Street Address
City State Zip Code Country
Email Address Contact Phone Contact Phone
Is this an organized or guided trip?
Yes
Group Name
No
TYPE OF BACKCOUNTRY USE REQUESTED (Check All That Apply)
Backpacking
Canyoneering/Rappelling
Stock Number of Stock:
River Use Indicate Type and/or Location of Use:
ITINERARY DETAILS (for more choices, submit additional pages)
CHOICE ONE CHOICE TWO
Group Size Entry Location Exit Location Group Size Entry Location Exit Location
DAILY ITINERARY DETAILS (use additional pages if necessary) DAILY ITINERARY DETAILS (use additional pages if necessary)
Trail / Route to be Taken / Trail / Route to be Taken /
Date Date
Camp Location / Use Area Camp Location / Use Area
Night 1 Night 1
Night 2 Night 2
Night 3 Night 3
Night 4 Night 4
Night 5 Night 5
Night 6 Night 6
Night 7 Night 7
Additional Choices: If all choices above are unavailable, the Backcountry Information Center will retry using options selected below:
Alternate Start Dates Trip Length (# of nights) Minimum Group Size
to
Similar/Nearby Campsites Reverse Itinerary Flexible Itinerary? Yes No
MODE OF TRANSPORTATION (for trailhead vehicles only, leave blank if unknown)
Vehicle (Including 4WD/Motorcycle): Parking Location Plate # State
Rental?
Yes No
METHOD OF PAYMENT
Method of Payment MasterCard Visa Discover American Express Use hiker credit on file
Name on Card Total Amount Authorized
$
Credit Card Number Expiration Date
Signature Date
RECORDS RETENTION. TEMPORARY. Destroy 3 years after closure. (NPS Records Schedule, Protection and Safety (Item 2) (N1-79-08-1))
Calculate Cost Estimate
Calculate Cost Estimate
NPS Form 10-404 (Rev. 04/2017) OMB Control No. 1024-0022
National Park Service Expiration Date 08/31/2020
NOTICES
Notice Regarding the Use of Cell/Satellite Phones and Personal Locator Beacons
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.
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. Do not send this application to this address but rather to the address at the top of the first page.
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Backcountry Permit Request (National Park Service)

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Completed 6 August 2020

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