Form 2930-1 - Special Recreation Permit Application
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Form 2930-1
UNITED STATES
FORM APPROVED
(February 2017)
DEPARTMENT OF THE INTERIOR
OMB NO. 1004-0119
Expires: January 31, 2020
BUREAU OF LAND MANAGEMENT
SPECIAL RECREATION PERMIT APPLICATION
Permit No.
(43 U.S.C. 1201; 43 U.S.C. 1701; 16 U.S.C. 6802; and 43 CFR 2930)
Type or Print Plainly in Ink
Instructions: Complete and return to appropriate BLM Office. (Use additional sheets, as necessary.)
2. Name of Business
1.
New Application
Permit Renewal
or Organization
Last Name
Middle Initial
3. First Name
4. Address
5. Phone No. (include area code)
6. FAX No. (include area code)
7. Email Address
8. Website
9. Applicant is:
Individual
Corporation
Government Agency
(If corporation, attach copy of Articles of Incorporation and Certificate unless already on file.)
10. Name(s) and phone number(s) (include area code(s)) of person(s) authorized to conduct business with BLM concerning the permit:
11. Application is for (check all that apply):
Commercial
Competitive Event
Organized Group
Vending
(Definitions of these permit types are provided on page 3 of this form.)
):
12. To use the following public lands/related waters (provide name, legal description and/or attach map or GIS data file as required by BLM
13. For the following purpose (attach a complete Operations Plan as required by the issuing BLM Office):
14. Dates of proposed use
Ending Date:
Beginning Date:
Other schedule:
Check if applying for a multiple year
permit, subject to annual authorization.
15a. Have you had a permit previously?
15.
Do you have a permit with BLM/USFS/NPS?
Yes
No
Yes
No
15b. Have you ever been denied or had a permit revoked?
15c. Have you forfeited a bond or other security?
Yes
No
Yes
No
15e. Have you been convicted, or paid a fine, or
15d. Do you have any unresolved, criminal, civil or
Yes
No
Yes
No
forfeited a bond, for violations regarding natural
administrative actions related to a permit or the
activities you plan to conduct under this permit?
resources, cultural resources or any activity
related to your proposal?
If the answers to any of the above questions are, “Yes:” Provide a detailed explanation on a separate piece of paper.
16.
Certification of Information: I CERTIFY the information in this application and supporting documents is true, complete, and correct to the best
of my knowledge and belief and is given in good faith.
I acknowledge that I (we) am (are) required to comply with any conditions or stipulations required by the BLM, including but not limited to the
General Terms listed on page 2 of this form.
(Signature of Applicant)
(Date)
Title 18 U.S.C. Section 1001 and Title 43 U.S.C. Section 1212 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.
(Continued on Page 2)
(Form 2930-1)
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