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MOTORIZED USE DISABILITY PERMIT APPENDIX - B Douglas County Forestry Department Application for Disability Permit to Use a Motor Vehicle in Closed Area Note: Only Class A or Class C permit holders, and those holders of Class B permits issued for more than one season, as defined in s. 29.193(2)(a)2 and 5, Wis. Stats., are eligible for this permit. If you are not in possession of a current Class A, Class B (issued for more than one season), or Class C permit, 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. Applicants Full Name Drivers License State & Number Street or Route Home Telephone Number Alternate Number City, State, Zip Code Class A, B (issued for more than one season) or C Permit # Date of Birth Eye Color Hair Color Weight Height Sex **These permits are area specific. Application must be made as an access route from point to point. Please indicate the legal description and provide a brief sketch of the road to be used. Section______ township. Description of intended activities or desired uses of property (this should include specific areas and times of year you wish to exercise this permit) List all vehicles you wish to use under authorization of this permit. Include license or registration number and make, model , color and year. License or Registration Description 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. The permit holder may have an assistant only if all information is added below. Please provide the full name, address, telephone number, and Driver’s License State and number of potential assistants. ---PAGE BREAK--- MOTORIZED USE DISABILITY PERMIT APPENDIX - B Please read all of the general conditions on the back of this form and sign where indicated. 1. This Permit may only be issued to those applicants holding a Class A, Class B (issued for more than one season) or Class C disability permit from the State of Wisconsin. If you are not in possession of a Class A, Class B (issued for more than one season) or Class C disability permit, you must first apply for and obtain one from the State of Wisconsin. 2. There is a limit of 4 approved permits per applicant per year. 3. Permits are valid for up to one 12-month period. 4. This permit must be in the applicant’s possession at all times while operating a motor vehicle under the conditions of this permit. A copy of this permit must also be displayed in a visible fashion on the dash of any vehicle parked at the access point and on the vehicle (OHV) when parked in a closed area. 5. Permits will not be issued for “low motorized” areas as defined in the Douglas County Access Management Plan. These are defined as resource management units 3, 11E, 11N, 11W, 22, the Douglas County Wildlife Management area, and St Croix River Corridor. 6. Permits may be issued for established roads and trails only. Cross-country travel is not allowed, including for game retrieval reasons. 7. Permits are issued for a specific access to and from a point, not for a general area. Motor vehicle travel is only allowed on the route defined on the map, which is made part of this document. 8. If the approved access point is through a gate, the permittee will provide a lock, which will be locked into the County Forest lock. This will allow for access for both the permittee and County Forest Personnel. 9. Vehicles used under this permit may not be operated in excess of normal walking speed. 10. The permit holder is allowed only one passenger to assist his or her activities. This passenger is not permitted to participate in the activities for which the motorized access is desired. For example, if the permittee has applied for hunting access, the passenger may assist but not hunt. 11. 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 April 1 – May 31of any given year. 12. Douglas County may deny any permit application in cases including but not limited to potential for environmental damage, active timber sales, sensitive areas, and safety concerns. 13. 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 corresponding citations and forfeitures, including restrictions from future permit applications. 14. Douglas County will require up to 10 full working days for permit review from date of submittal. 15. Costs associated with any medical and chiropractic examinations are the responsibility of the permit applicant. Signature of applicant Date Signed (Map to be inserted below by Douglas County) Leave this section blank – to be used by Douglas County Forestry Department Date Submitted Approved Denied (if approved, see specific conditions listed below.) Specific Conditions (authorized by Director of Forestry & Natural Resources or designee) Permit expiration date Director of Forestry and Natural Resources Signature or designee Date Signed By signing this agreement, the permittee agrees to all the terms and conditions contained herein. Violations of any of the terms of this agreement will immediately render this permit null and void. Signature required below only after approval of this permit by Douglas County. Permit is valid once signed. Permittee’s Signature Date signed