Special Use Permit Application

* Required Fields

Research Title: *

Name: *

Position: *

Address: *

Please include street address, city, state and zip code.

Email Address: *

Phone Number: *

Field of Interest: *

General field of interest, professional qualifications, and institutional affiliation

Proposed Visits and Activities

Name of Natural Area(s): *

Frequency and Length of Visit(s): *

Duration of Project (with dates): *

Description of Activities: *

Include number in party and use of equipment in natural area

Ecosystem Impacts: *

Explanation of ecosystem impacts and/or significant negative impacts within the Natural Area

Project Details

Objectives: *

Succinct narrative, preferably including context and relevance to ecology, management, Extension, and teaching

Methods and Procedures: *

Records to be Kept: *

Proposed Location(s): *

GPS coordinates or GIS shapefiles

Project Needs: *

Include need for restricted activities by others, if applicable

Finishing: *

Strategy to remove all research materials and equipment when finished, along with impermanent markers, such as flags and flagging

Collecting (Including Capture and Release)

Species or Materials: *

Number of Specimens: *

Disposition of Specimens: *

Methods of Collecting: *

Other Disturbances to be Made: *

Other Information: *

List all permits held, and any other pertinent information

Certification: *

I certify that I have read and understand the permit requirements for this application and that this application and the above supplied information is true and accurate to the best of my knowledge.

Date: Wednesday, February 8, 2012 - 5:55pm