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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 (first, middle initial, and last) Address (include zip code) Phone (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 the State of Resident Corporation Local Government Other (Check appropriate box at right and explain.) 5. Are the lan.

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