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2. Disclaimer
   Information submitted on this form will be sent via unsecured email. To protect sensitive information, do not enter the following items or similar information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, credit card numbers, medical information, passport numbers, and passwords. Please review our privacy policy located at www.jeffco.us/privacy. By submitting this form, you acknowledge and accept the terms listed in the privacy policy.
4. Research and Collections Permit Application
   In order to ensure sufficient time to process your permit, please submit this form no less than ten business days prior and no more than six months in advance of the date your proposed collection and/or research activities.
6. Company, Group Name, or University Affiliation *
8. Contact Information

   Provide name and contact information of Primary Investigator (PI). Permit will be mailed to this address unless you would prefer to pick up at office location

10. First Name*
11. Last Name*
12. Title (if applicable)
14. Address*
16. Address Line 2
18. City*
19. State*
20. Zip Code*
22. Phone Number*
23. Email Address*
27. Park(s) Requested*
    Please ensure that the area that you are requesting is managed by Jeffco Open Space
28. Specific Area Within Park*
29. Date and Time Requested*
    Date and Time Requested Start Date

    Date and Time Requested Start Time

    —

    Date and Time Requested End Date

    Date and Time Requested End Time
    Please list your anticipated start and finish
33. Detailed Description of Collection/Research Activity *
    Please provide as much detail as possible and add specific dates and times if more than one
35. Describe how collected specimens or material will be used (if applicable)
37. Describe Measures That Will Avoid or Minimize Impacts to Natural Resources and/or Visitor Experiences *
39. Additional Permits (e.g., Colorado Parks and Wildlife, USFWS) Required for Activity (if applicable)
    Please provide the status of additional permits where applicable
41. Will your activity impact adjacent public right-of-way, private properties or surrounding landowners or businesses?*

    1. Yes
    2. No
43. If yes, please explain
47. Total Number of Participants*
48. Total Number of Vehicles*
50. Vehicle Description(s) with License Plate Info*
54. Certificate of Insurance

    Please upload your Certificate of Insurance. Jefferson County must be added as an additional insured to general liability policies. Certificate Holder must be:

    Jefferson County, Colorado
    c/o IMA Certificate Compliance
    1705 17th Street, Suite 200
    Denver, CO 80202 

56. Attachment 2 (if applicable)
60. Terms and Conditions*

    1) Permit must be on-hand and visible during all portions of collection/research 2) All vehicles with logos, or vehicles entering areas that are not designated for vehicles must display JCOS vehicle tag (will be provided) while parked and/or operating on JCOS managed land 3) Permits is valid only for the date and time requested. 4) Permit does not grant exclusive access to any area, trail, or route 5) All vehicles must be parked in a legal manner and outside of designated lanes of traffic 6) Permit is for your group, and your group only. Additional companies or organizations may not be added and must apply for their own permit 7) No trails will be closed for event(s), and all participants are expected to abide by proper trial etiquette and yielding practices 8) All JCOS Park Regulations apply, outside of those which are specifically addressed in this permit. Rules and Regulations can be found at https://www.jeffco.us/1583/Regulations 9) Permit may be revoked by JCOS at any time for any reason, including cases of misconduct

    1. I agree.
62. Electronic Signature Agreement*

    I (we) hereby swear or affirm, under penalty of perjury, that the information given here is true and correct. The typed signature below indicates this individual, or the legal entity the individual represents (as applicable), accepts responsibility for the activity and agrees to the terms and conditions of this agreement.

    1. I agree to the terms and conditions
64. Electronic Signature*
68. Receive a Copy of Your Submission
    By checking the box below, you will receive a copy of the application you are submitting; however, this does not mean that your application has been approved. We will contact you within 10 business days to let you know the status of your application.
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

* indicates a required field