CBS #
CBS #
LD
FOR OFFICIAL USE ONLY – Permit Information Box
Party Leader
PS
ADD +
CAN NU
CHANGES: Name of Person / Caller
Date
ADD +
CAN -
CBS Total
Cal Total =
CBS Total
$ Paid
$
$
$
Rogue River Noncommercial Permit Confirmation Sheet
Type or print complete legal names and street (home) addresses of all party members. Changes to party
members (not Party Leader) may be made at check-in. Enclose a nonrefundable $10.00 processing fee for
each party member. Make checks payable to USDI-BLM. Do not send cash. This confirmation sheet and
fee must arrive at the Smullin Visitor Center by 3:00 p.m. no later than ten days before your permitted
launch date or your permit will be canceled.
Physical / Street Addresses Only.
11.
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17.
No PO Box’s
Party Leader
1. ________________________________
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Alternate Party Leader
2. ________________________________
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3. ________________________________
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4. ________________________________
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5. ________________________________
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6. ________________________________
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7. ________________________________
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8. ________________________________
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9. ________________________________
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10. ________________________________
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20.
For Credit Card Payment Only:
Visa/MasterCard/Amer.Express/Discover #_____________________________________________ Amount__________
Cardholder’s Name______________________________________________________
Exp. Date________________
Billing Address_______________________________________ ____________________ Phone________________