Form 4710-24 MHF & BLM Facility Requirement Form

FORM 4710-24

(March 2018) OMB NO. 1004.0042

UNITED STATES Expires: February 29, 2020

DEPARTMENT OF THE INTERIOR

BUREAU OF LAND MANAGEMENT

MHF & BLM FACILITY REQUIREMENT FORM

Trainer Name: ________________________________________ Phone: _______________________

Adopter Name (If trainer is a youth): _________________________________________

Address/P.O. Box: ______________________________________ City: ______________________ State: __________ Zip: ____________

Email Address: ____________________________________________ Date of Birth: ________________________________

Are you interested in training horses or burros? Yes No How many? __________ Horses __________ Burros

How many untitled animals are at the facility location: _________ Status- Adopted (Untitled): __________ TIP: ___________ EMM:____________

Describe your facility: (Facility refers to an enclosed area such as a corral, barn, stall, etc. Materials used may include: pipe panels, wood post, planks, horse fence, etc.)

1. Corral: Length: ______________ Width: _________________ Height of Corral:

Gate Height: Gate Width:

Materials used in Corral Materials used in Gate ______________________

2. Shelter: Type of Shelter: _____________________________ Materials used in Shelter (If Applicable):

Length: Width: Included within corral sq. footage? Yes No

Attached to Corral? Yes No If not attached, how is it accessible? _______________________________

3. Feed: Type of Hay or Pasture: Supplemental Feed: Amount per day: _______________ d) Water: Is there access to a water source? Yes No

If yes, select your water source: Well City Automatic Water Other: ____________________________________________

e) Trailer: Type of trailer Stock Horse Homemade Capacity (No. of animals): ___________________

Dividers* Yes No If yes, can they be tied or folded back? Yes No Number of rear doors: 1 2 Rear Door: Full Height Half Height Ramp* Yes No Is trailer covered? Yes No

Solid top? Yes No If not, describe the type of cover? *Additional restrictions apply, please contact an authorized officer.

Draw a map to the facility (from the nearest major highway) & provide directions to your location using the lines below.	Draw a layout of the corral(s) and shelter(s) & provide a brief description using the lines below.
N	N

*Address of facility if different: ______________________________________________________________ _____________________________________

Directions to facility: ___________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

Signature: _______________________________________________ Date: __________________________________

BURDEN HOURS STATEMENT

Public reporting burden for this form is estimated to average 30 minutes per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to U.S. Department of the Interior, Bureau of Land Management (1004-0042), Bureau Information Collection Clearance Officer, (WO-630), 1849 C Street, N.W., Washington, D.C. 20240.