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B. CLIENT'S ACKNOWLEDGMENT OF RISK FORM. If you plan to use an acknowledgment of <br /> risk form, attach a copy. <br /> Our Student Agreement/Waiver and Release of Liability form has been attached. <br /> 9. EXPERIENCE. List all permits for outfitting and guiding on National Forest System lands that <br /> you have held in the past 3 years. If you received a performance evaluation from the Forest <br /> Service, attach a copy. If you are relying on outfitting and guiding experience with other federal <br /> or state agencies, list any permits that you have held with those agencies in the past 3 years <br /> and provide a copy of any performance evaluations received. List all citations or violations <br /> received in association with outfitting and guiding activities. <br /> We have held no permits for outfitting and guiding before this time. <br /> 10. SIGNATURE. I hereby certify that I am of legal age and am authorized to do business in the <br /> State or Commonwealth of Colorado. I have personally examined the information contained in <br /> this application and certify that this information is correct to the best of my knowledge. I hereby <br /> acknowledge that is an application only, and that the use and occupancy of National Forest <br /> System lands is not authorized until a special use permit is signed and issued by an authorized <br /> officer. <br /> Printed Name: ZAN AA. .Scumg--£ignature: ` <br /> Date: 2 -/4 -/ <br /> Printed Name: Signature: <br /> Date: 2— <br /> 18 U.S.C. § 1001 makes it a crime for any pe on knowingly and willfully to make to any <br /> department or agencq of the United States any false, fictitious, or fraudulent statements or <br /> representations as to any matter within its jurisdiction. Anyone who knowingly or willfully makes <br /> or uses any false statements or representations shall be fined not more than $10,000 or <br /> imprisoned not more than five years, or both. <br />