Naval Weapons Station Charleston

JOINT BASE CHARLESTON

HUNTING AND FISHING PERMIT APPLICATION

PLEASE PRINT: SS # (last four digits) ___________ BIRTH DATE ________________________

NAME______________________________________________________________________________

RANK/RATE/TITLE LAST FIRST MI

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STREET OR POB CITY ZIP

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PHONE E-MAIL ADDRESS

Category A : Category B:

1. General Public _____ 1. Active Duty Military _____

2. DoD Contractor _____ 2. Retired Military _____

3. Dependent of 1 or 2 (circle one) _____ 3. DoD Civilian _____

4. JB CHAS Game Warden _____

5. Dependent of 1, 2, 3 or 4 (circle one) _____

I am requesting permission to Hunt and/or Fish (circle one or both)

State Hunting/Fishing License # _______________________________________________

State Hunter Education Card # ______________________ Issuing State ___________

In consideration for permission to hunt/fish on Joint Base Charleston, I hereby:

a. For myself and my heirs and administrator, hold the United States, its Officers, Agents and Employees, harmless from any damage claim for death or injury to my person and for any damage to or destruction of my property that may occur as a result of my presence on Joint Base Charleston property, whether such injury or damage results from negligence of the United States, its officers, Agents, Employees, Contractors or otherwise. I further agree to indemnify and save harmless the United States, its Officers, Agents, Employees, and Contractors from any damage claims by third parties for death, injury, or property damage that may arise by reason of my negligence in any respect while on Joint Base Charleston property pursuant to this permit;

b. Agree to fully comply with all Federal and State Hunting and Fishing laws and regulations and applicable Joint Base Charleston regulations while engaged aboard;

c. Certify I have read and understand Joint Base Charleston hunting and fishing regulations as provided in Joint Base Charleston Hunting and Fishing Program Plan; and

d. Certify that the terms, conditions, and limitations of this application are fully understood and accepted without reservation.

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APPLICANT SIGNATURE JB CHAS EMPLOYEE

Office Use Only:

DATE _______________ PERMIT# ______________ CATEGORY ______ $ ___________