Application for Mail-Order Sales of the America the Beau

OMB Control No. 1024-0252
Expires XX/XX/2017

APPLICATION FOR MAIL ORDER SALES OF THE
AMERICA THE BEAUTIFUL – THE NATIONAL PARKS AND FEDERAL
RECREATIONAL LANDS ACCESS PASS
U.S. Department of the Interior – Bureau of Land Management, Bureau of Reclamation, Fish and Wildlife Service,
National Park Service --- U.S. Department of Agriculture – Forest Service

About the Access Pass:
The Access Pass is a free, lifetime pass available to United States citizens or permanent residents, regardless of age, that
have a permanent disability. The Pass can be used at over 2000 Federal recreation sites across the nation, including
National Parks, National Wildlife Refuges, and many National Forest lands. The Access Pass admits the Pass owner and
any passengers traveling with him/her in a non-commercial vehicle at per-vehicle fee areas or the Pass owner and three
additional adults where per-person fees are charged. The Access Pass may also offer a discount on some expanded amenity
fees, such as camping. Discounts offered by the Pass vary widely across the many different types of recreation sites. Pass
owners are encouraged to check with sites they plan to visit before obtaining a pass to verify that their Pass will be
accepted. Anytime a Pass is used, photo identification will be requested to verify Pass ownership.
How to Obtain an Access Pass
The pass may be obtained two ways, either at a federal recreation site where entrance or standard amenity fees are charged
or through the mail. To obtain a pass you must have identification to verify that you are a U.S. citizen or permanent
resident, which could include:
A US State or Territory issued Drivers License, Identification or Birth Certificate
A US Passport or Passport Card
A Permanent Resident Card (Green Card)
You must also have documentation that you have a permanent disability, which could include:
A statement signed by a licensed physician attesting that you have a permanent physical, mental, or sensory
impairment that substantially limits one or more major life activities, and stating the nature of the impairment;
OR

A document issued by a Federal agency, such as the Veteran’s Administration, which attests that you have been
medically determined to be eligible to receive Federal benefits as a result of blindness or permanent disability.
Other acceptable Federal agency documents include proof of receipt of Social Security Disability Income (SSDI)
or Supplemental Security Income (SSI);
OR

A document issued by a State agency such as the vocational rehabilitation agency, which attests that you have been
medically determined to be eligible to receive vocational rehabilitation agency benefits or services as a result of
medically determined blindness or permanent disability. Showing a State motor vehicle department disability
sticker, license plate or hang tag is not acceptable documentation.
Obtaining a Pass Through the Mail
To obtain an Access pass through the mail you must complete this application, provide a photocopy of proof of citizenship
or residency, documentation of disability and pay the processing fee. The cost of obtaining an Access Pass through the
mail is ten dollars ($10) for processing the application (the Pass is free).
Obtaining a Pass in Person
If you apply for an Access Pass at a Federal recreation site you do NOT need to fill out this application. When you arrive at
the recreation site, the officer selling the pass will verify your documentation of disability and that you are a U.S. citizen or
permanent resident by checking your ID. You will then be issued the Pass. The Pass is free if obtained in person, there is
no processing fee. Before making a trip to obtain a Pass, be sure to contact the site to ensure that they have passes
available.
Replacement Passes
Lost or stolen Passes cannot be replaced at this time. If your pass has been lost or stolen you must obtain a new one. Worn
or damaged Passes can be replaced free of charge at any recreation site where Passes are issued, or through the mail by
returning the Pass with this application and paying the ten dollar ($10) processing fee.

OMB Control No. 1024-0252
Expires XX/XX/2017

APPLICATION FOR THE AMERICA THE BEAUTIFUL – THE NATIONAL PARKS AND FEDERAL
RECREATIONAL LANDS ACCESS PASS
U.S. Department of the Interior – Bureau of Land Management, Bureau of Reclamation, Fish and Wildlife Service,
National Park Service --- U.S. Department of Agriculture – Forest Service

Your mail application for an Access Pass must include:

Product #209291

1. This completed, signed application form.
2. Photocopy of documentation issued by Social Security Disability, Office of Veterans Affairs and/or a
licensed physician that demonstrates permanent disability.
3. Photocopy of documentation issued by an authorized U.S. agency that demonstrates U.S. citizenship or
permanent residence. (driver's license, passport, state issued ID).
4. Payment of the processing fee by either Credit Card, Check or Money Order.
5. For a pass replacement please submit the original worn pass.
**Do Not Send Original Documents**
Please Print Clearly - Your name should appear as it does on your Photo ID

Middle

First Name

Last Name

Mailing Address
City

State

Zip Code

Day Time Telephone
E-Mail Address
By submitting this application:
I hereby affirm that I am a citizen of or domiciled in the United States, and that I have been medically determined to have
a permanent physical, mental, or sensory impairment that severely limits one or more major life activities. Major life
activities include functions such as: caring for oneself, performing manual tasks, walking, seeing, hearing, speaking,
breathing, etc. (Section 504 of the Rehabilitation Act of 1973, as amended, 29 USC § 705 20)).
Signature:

Date

Payment
Credit Card

Visa

MasterCard

American Express

Discover
Exp. Date

Credit Card Number:

You may also pay by check or money order - payable to USGS for $10

Send your completed Application to:

USGS
Attn: Access Pass
Box 25286
Denver, CO 80225

Questions: fedrecpass@usgs.gov
1-888-ASK-USGS
(1-888-275-8747)

Federal Law 18 U.S.C. 1001 makes it a crime in any matter within the jurisdiction of any department or agency of the United States for
any person knowingly and willfully to falsify, conceal, or cover up by any trick, scheme, or device a material fact; to make any materially
false, fictitious, or fraudulent statement or representation; or to make or use any false writing or document knowing that it contains a
materially false, fictitious or fraudulent statement or entry. Violations of 18 U.S.C. 1001 are punishable by fines of up to $10,000,
imprisonment of up to five years, or both.
Public Burden Statement: The public burden for the collection of information is estimated to be 10 minutes per response, including the time for
reviewing instructions, gathering and maintaining data, and completing the form. Comments regarding the burden estimate or any aspect of this
collection of information may be sent to the Information Collection Clearance Officer, National Park Service, 1849 C St., NW (2601), Washington, D.C.
20240.
Paperwork Reduction Act Statement: A Federal agency may not conduct or sponsor and you are not required to respond to a collection of information
unless it displays a valid OMB control number. This information is collected to determine adequate proof of disability and residency. The obligation to
respond is required to obtain the Interagency Senior Pass. The application and all documentation will be returned to the applicant or destroyed upon
issuance or denial of the pass.