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1 of 2 Douglas County Forestry Department APPLICATION FOR DISABILITY PERMIT TO USE A MOTOR VEHICLE IN RESTRICTED AREA Note: Only Class A or Class C disability permit holders, and those holders of a valid Class B Shoot from Vehicle disability permit issued for more than one season, as defined in s. 29.193(2)(a) 2 and 5, Wis. Stats., are eligible for this permit. Disabled Hunt with Crossbow permits do not qualify. If you are not in possession of a current Class A, valid Class B Shoot from Vehicle (issued for more than one season), or Class C disability permit issued by the State of Wisconsin, you must first apply for and obtain one before receiving this permit. Please read all conditions of this permit listed on the front and back of this form before applying. Applicant’s Full Name: Valid Drivers License State & ID Number: Street Address: Home Telephone Number & Cell Number: City, State, Zip: Class A, B (issued for more than one season), or C Permit Number: Date of Birth: Eye Color: Hair Color: Weight: Height: Sex: Email Address: Permits are road specific. Application must be made for a specific access road from point to point. In order to optimize efficiency and turn- around time, please be as detailed as possible when describing or identifying the road(s) being requested for motorized access. Applicants are encouraged to attach a clearly labeled detailed map indicating exact roads. Section N - R W; Township. Purpose of this application: Please include a description of intended activities or desired uses of the property (this should include specific activities and times of year you wish to exercise this permit). Attached additional sheets as necessary. List all vehicles you wish to use under authorization of this permit. Include valid license or registration number and make, model , color and year. License or Registration Number Description (year, make, model, and color) If authorized, this permit allows ONE passenger to accompany permit holder to act as an assistant. The passenger must accompany the permit holder at all times and is not permitted to take part in the activities described on this permit under any circumstances. You may identify two potential assistants with this application by completing all required information below, but only one of the two is permitted to accompany you at any one time. ASSISTANT 1 Assistant’s Full Name: Valid Drivers License State & ID Number: Street Address, City, State, Zip: Home Telephone Number & Cell Number: ---PAGE BREAK--- 2 of 2 ASSISTANT 2 Assistant’s Full Name: Valid Drivers License State & ID Number: Street Address, City, State, Zip: Home Telephone Number & Cell Number: General Permit Conditions: 1. Original copy of a valid disability permit shall be provided at the time of application. A photocopy will be retained by the County. 2. Original copy of a Driver’s License or other approved photo identification shall be provided at the time of application. A photocopy will be retained by the County. 3. Permit applications for the purpose of hunting, fishing, trapping, or related activities, must be accompanied by a valid WDNR license issued in the Permittee’s name for the current calendar year. A photocopy will be retained by the County. Permits will not be issued for bear hunting unless a valid kill tag in the Permittee’s name is provided. 4. Permits are valid for the calendar year in which they are applied for. 5. There is a limit of 4 approved permits per applicant per single segment of access road per calendar year. However, a single permit may cover up to 4 single segments of access roads per applicant per calendar year. Permits will not be issued for general areas. 6. Permit (original copy) must be in the applicant’s possession at all times while operating the motor vehicle on the permit approved road or trail. 7. Permit (original copy) must be clearly displayed in a visible fashion in the vehicle in the event the vehicle is parked or left unattended on the permit approved road or trail. 8. The Permittee shall noticeably display a weather resistant sign at least 35 inches square on which is clearly written “DISABLED HUNTER” on the vehicle(s) that is operated on or parked on the permit approved road or trail. The sign shall remain continuously displayed on the vehicle(s) for the entire time the Permittee is using the road or trail. 9. Permits will not be issued for “Low Motorized” areas as defined in the Douglas County Access Management Plan. These are defined as the Poplar River Block, Douglas County Wildlife Management Area Block, Spruce River Block, Coppermine Block, Pokegama River Block, and the St. Croix Wild and Scenic Riverway Block. 10. Permit allows motorized vehicle access for the sole purpose herein to lands owned by Douglas County as defined herein, including any map exhibits, which are attached hereto and made a part hereof. It is the responsibility of the Permittee to know the location of the approved and non-approved roads and trails. 11. Permits are issued for established roads and trails only. Cross-country motorized travel is prohibited under all circumstances. 12. In the event the approved access point is through a gate, the permittee shall provide a lock to the County which will be locked into the County lock is such a fashion to provide access for both parties independent of the other. Type of lock shall be consistent with gate design. The gate shall remain closed and locked at all times other than when passing through. 13. Vehicles used under this permit may not be operated in excess of normal walking speed and safety should be exercised at all times. Roads are not guaranteed passable. Ride at your own risk. 14. No more than 2 assistants can be identified. The permittee is allowed only one of these assistants to assist with his or her activities at any one time. The assistant is not permitted to participate in the activities described herein. For example, if the permittee has applied for hunting access, the assistant may assist but cannot hunt. 15. Permit may be issued for any legal activity on the County Forest, but access may be restricted seasonally or for other pertinent reasons. All permits will be automatically suspended from March 14th – April 30th of any given year. 16. Douglas County reserves the right to deny any permit application or to terminate or modify any approved permit at any time as it deems necessary. This includes, but is not limited to potential for environmental damage, active timber sales, sensitive areas, safety concerns, etc. 17. Violations to the terms of this permit will immediately render this permit null and void and subject the permittee to the terms of the Douglas County Land Recreation Ordinance #7.2 and any corresponding citations and forfeitures, including restrictions from future permit applications. 18. Douglas County will require up to 10 full working days for permit review from date of submittal. By signing this permit application, you fully understand, agree with, and commit to all terms and conditions herein including those of any attachments. Violations of any of the terms of this agreement will immediately render this permit null and void. Application is not valid until signed. Signature of Applicant: Date Signed: Leave this section blank – to be used by Douglas County Forestry Department Date Received: APPROVED (see specific conditions below) DENIED (see reasons below) Specific Conditions of this Permit or Reasons for Denial (attach sheets as necessary): (Attached County produced map if necessary) Permit Expiration Date: By Director of Forestry & Natural Resources or Designee: Date: