National Park Service U.S. Department of the Interior Glen Canyon National Recreation Area Page, Arizona
Commercial Use Authorization - Application Request Form Name:____________________________________ SSN or Fed Tax ID #:_____________________ Company Name:___________________________________________________________________ Mailing Address:___________________________________________________________________ City/State/Zip:_____________________________________________________________________ Physical Address (if different from mailing address):_______________________________________ City/State/Zip:_____________________________________________________________________ Business Phone: _____________________________ Fax:_________________________________ Cell Phone:__________________________________ Pager:_______________________________ Email:_______________________________ Website URL: ________________________________ Business is being conducted as (check one):
Sole Proprietorship Partnership Corporation Limited Liability Company
Other:_________________________________________________________________________________________
Person(s) authorized to sign on behalf of the business (name and title):_______________________ ________________________________________________________________________________ Type of CUA requested (check all that apply):
Vessel Caretaking Guided Kayak/Canoe & Instruction Guided Hunting Land-Based Tours (Backcountry Roads) Marine Salvage Launch, Retrieval & Boat Hauling – Vessels & Houseboats (Privately Owned Only) Minor Vessel Repair
Guided Fishing Guided Backpacking/ Hiking
Scuba Diving Excursions & Instruction
Waterski/Wakeboard Instruction
Rev. 01/19/07
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Description of Services to be provided under the CUA:_____________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Locations where services will be provided (check all that apply):
Wahweap Hite Stateline Backcountry Bullfrog Lake Powell Halls Crossing Lees Ferry
COMMENTS:_____________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
I certify the information provided on this form is true and accurate to the best of my knowledge.
SIGNATURE:_____________________________________________ DATE:__________________
Mail this request form to: National Park Service Glen Canyon National Recreation Area Attn: CUA Program P.O. Box 1507 Page, AZ 86040-1507 or Fax: 928-608-6259
Rev. 08/25/06
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