PERMITAPPLICATION

Applicant Name_______________________________________________

DBA _______________________________________________________

Address _____________________________________________________

Telephone________________________ FAX______________________

This PERMIT is issued by SELDOVIA NATIVE ASSOCIATION, INC. and accepted by the applicant, subject to the terms and conditions of the SELDOVIA NATIVE ASSOCIATION, INC. on the subject to the terms and conditions of this permit. The Applicant, on the Applicant's behalf, and on behalf of all Applicant's party by acceptance of this permit, certifies that he/she has read and is familiar with the terms and conditions, that all activities will be performed in strict compliance with said regulations, and has reviewed the maps & exclusion areas for no trespassing.

I HEREBY CERTIFY THAT ALL THE ABOVE INFORMATION IS TRUE AND CORRECT AND I FURTHER ACCEPT THE CONDITIONS AND STIPULATIONS ON BOTH SIDES OF THIS AGREEMENT.

Signature of Applicant_______________________ Date________________

Signature of Associations Representative_______________ Date__________

Additional Group Members

NAME	ADDRESS	PHONE

Seldovia Native Association, Inc. PO Drawer L. 99663 Ph.(907) 234-7625 Fax. 234-7637
TO VALIDATE THIS PERMIT, you must call SNA at (907) 234-7625 prior to mailing in this form and required fee. This form may be faxed to (907) 234-7637. This permit is NOT VALID WITHOUT AN AUTHORIZED SIGNATURE from the corporation office.