2. Division of Natural Resources
   141 Keyes Road, Concord, MA 01742 Tel: 978-318-3285 Fax: 978-318-3291
3. APPROVAL
   Submittal of this form does not constitute approval. Activities on conservation land requiring a permit must be submitted at least one week in advance of the date of the proposed activity and are subject to approval by the Natural Resources Director. Conditions of approval may be required at the discretion of the Natural Resources Director.
5. Name of Organization/Applicant*
6. Name of Conservation Land*
8. Email*
10. Date & Times Requested*
    Date & Times Requested Start Date

    Date & Times Requested Start Time

    —

    Date & Times Requested End Date

    Date & Times Requested End Time
11. What is the purpose of the event/outing for which a permit is being sought?*
13. Name of Leader in Charge*
14. Complete Mailing Address for Leader in Charge*
16. Contact Number for Group Leader*
    Please provide a number where you may be reached on the actual day of your event. This number will not be shared, but may be used in the case of an emergency or for notifications regarding land use on the day of your event.
17. Size of Group*
19. Vehicle Make and Model*
20. Vehicle License Plate #*
22. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
24. Electronic Signature*
25. Date Signed*
    Date Signed
27. Terms & Conditions
    This permit must be carried by the leader in charge and may be revoked if the user(s) do not follow the conditions. I hereby certify that I have read and understood the Concord Conservation Land Regulations and agree to abide by them. The Permittee shall indemnify and save harmless the Town of Concord and all of its officers, agents and employees for any suits, causes of action, claims, judgments or other liability, including without limitation reasonable counsel fees and expenses that may arise as a result of Permittee's use of Town Conservation Land. The Permittee may be required to provide to the Town of Concord, prior to the date of use of Town property, a certificate of insurance evidencing that the Permittee carries insurance with a licensed insurance company acceptable to the Town. Such insurance shall name the Town of Concord as an additional insured and shall not be cancelled or modified prior to the completion of use of Town property.
29. I agree to the terms & conditions above.*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
31. Electronic Signature*
33. APPROVAL- Reminder
    Submittal of this form does not constitute approval. Activities on conservation land requiring a permit must be submitted at least one week in advance of the date of the proposed activity and are subject to approval by the Natural Resources Director. Conditions of approval may be required at the discretion of the Natural Resources Director.
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field