Form 2920-1
FORM APPROVED
(March 2011)
OMB NO.1004-0009
UNITED STATES
Expires: March 31, 2014
DEPARTMENT OF THE INTERIOR
FOR BUREAU OF LAND MANAGEMENT (BLM) USE ONLY
BUREAU
OF LAND MANAGEMENT
LAND USE APPLICATION AND PERMIT
Application Number
(Sec. 302(b) of P.L. 94 - 579, October 21, 1976, 43 U.S.C. 1732)
1.
Name
Address
Phone
(first, middle initial, and last)
(include zip code)
(include area code)
2. Attach map or sketch showing public lands for which you are applying
to
3. Proposed date(s) of use: from
4. Give legal basis for holding interest in lands in
Resident
Partnership
the State of
County
Corporation
(Check appropriate box at right and explain.)
Local Government
State Government
Other
5.
Are
the lands now improved,
occupied
or used?
Yes
No
(If
"yes," describe improvements and purposes,
identify
users and occupants.)
6. Do you need access to the land?
Yes
No (Describe needed or existing access)
7a. What do you propose to use the lands for?
b. What improvements and/or land development do you propose? (To complete application processing, engineering and construction drawings
may be required)
d.
c. What is the estimated capital cost?
What is the source of water for the proposed use?
$ _________________________________
I
CERTIFY That the information given by me in this application is true, complete, and correct to the best of my knowledge and belief and is given in good faith.
(Signature of Applicant)
(Date)
Title 18 U.S.C. Section 1001, makes it a crime for any person knowingly and willfully to make to any department or agency of the United States
any false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction.
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