1. Name of the Peak: .................. height ...............
2. Climbing Period: From .............. To: ...................
3. Trekking Route: ...............................................
4. Climbing Route: ...............................................
5. Name, Nationality & Passport No of the Leader of the team granted permit: ...........................................
Name: ...............................................................
Nationality: ........................................................
Passport No: ......................................................
6. Name, Nationality & Passport No of the team members:
(List may be attached)
Name: ................. Nationality: ......... PP No ...........
Name: ................. Nationality: ......... PP No ...........
Name: ................. Nationality: ......... PP No ...........
Name: ................. Nationality: ......... PP No ...........
Name: ................. Nationality: ......... PP No ...........
Name: ................. Nationality: ......... PP No ...........
7. Name of the representative in Kathmandu: ............
8. Name of the Sirdar / Guide: .......... ID Card No ......
9. Office of the Sirdar / Guide: ...............................
10. Permission granted for ........ Persons.

Note 1. please take your trekking permit from the Central Immigration Office for this expedition.
Note 2. We would like to request you to send us a detailed report together with photographs of the peak you climbed. This will help us in publishing a guide book in the future.
Signed: ..............................................
General Secretary, Nepal Mountaineering Association