Form 10-741a APPLICATION FOR A SCIENTIFIC RESEARCH AND COLLECTING PER

APPLICATION FOR A SCIENTIFIC
RESEARCH AND COLLECTING PERMIT
United States Department of the Interior
National Park Service

OMB # (1024-0236)
Exp. Date (6/30/2007)
Form No. (10-741a)

If you are not using the automated system to prepare this application,
please fill out this form and return it to the appropriate park.
All or some of the information you provide may become available to the public.
Name of the National Park System area(s) you are applying to:
Select one of the following: [ ] New application
[ ] Renewal of a previously issued permit
[ ] Modification of a previously issued permit

Please enter numbers for permit renewal or modification requests:
Previously assigned NPS study number:
Previously assigned NPS permit number:

Contact information for the current principal investigator
Office phone #:
[Dr., Mr., Mrs., Ms.] First name:

Last name:

Mailing address

Alternative phone #:
Office FAX #:

Name of the current institution represented

Office email address of principal investigator:

Additional investigators or key field assistants (first name, last name, office phone, office email)

Scientific Study Information
Project title (maximum 300 characters)

Purpose of the study (maximum 4000 characters)

Summary of proposed field methods and activities (extract from the study proposal where appropriate - maximum 4000 characters)

Study Schedule

Field Schedule

Initial starting date of the study:
Estimated date the entire study may end:

Activity Type (select one):

Research ____

Date to begin study within the park this application year:
Date to end study within the park this application year:
Will field study need to continue within the park next year (Yes/No):
Inventory ____

Monitoring ____

Other ____

Do you anticipate receiving funding assistance from the U.S. Federal Government for this study? (Yes or No)
If “Yes,” specify the agency(s):
Where will data, maps, photos, etc. (not specimens) reside upon completion of this study?
Location(s) where you propose activities will take place within the National Park System area(s):

Your proposed method of access (vehicles, aircraft, boat, snowmobile, foot, etc.):

The National Park Service may not conduct or sponsor, and a person is not required to respond to, this collection of information unless it displays a currently valid
OMB control number.
(appformscif.doc; revised 04/13/2004) Page 1 of 3

APPLICATION FOR A SCIENTIFIC
RESEARCH AND COLLECTING PERMIT
United States Department of the Interior
National Park Service

OMB # (1024-0236)
Exp. Date (6/30/2007)
Form No. (10-741a)

If you are not using the automated system to prepare this application,
please fill out this form and return it to the appropriate park.
All or some of the information you provide may become available to the public.

Handling or Collection of Specimens
Would you like to handle or collect specimens? (Yes or No)
If you respond “Yes,” please complete this entire section of the application (otherwise you may skip the remainder of this section).
Scientific description of specimens to be handled or collected (include taxonomic group or name, or type of material; sample size, quantity,
frequency, and location):

Proposed disposition of specimens identified for handling or collection (mark all that apply):
[ ] Temporarily captured or handled (may include marking) and then released undamaged in place
[ ] Will be destroyed through analysis or discarded after analysis
If you propose that specimens or materials be retained permanently, they will become part of National Park Service collections. You may
request that such specimens or materials be loaned to one or more non-NPS institutions for management. If you do make this request, you
accept responsibility for obtaining and submitting to NPS the signature of the official at each proposed repository using the form attached
as Appendix A.
[ ] Permanently retained in National Park Service collection, maintained in NPS repository
[ ] Permanently retained in National Park Service collection, maintained in one or more non-NPS repositories identified in
attached Appendix A (complete and submit an Appendix A for each proposed repository)

Certification
I certify that this application is accurate and complete. I understand a formal study (research) proposal for new or modified studies must
be provided to NPS before this application can be considered. I authorize the National Park Service to seek peer reviews of my proposal.
Signature of principal investigator:
For National Park Service use only

_______________
Date received

Assigned study number

Date: _________________________
Assigned permit number

Paperwork Reduction Act Statement: A federal agency may not conduct or sponsor, and a person is not required to respond
to a collection of information unless it displays a valid OMB control number. Public reporting for this collection of information
is estimated to average 1.625 hours per response, including the time for reviewing instructions, gathering and maintaining data,
and completing and reviewing the forms. Direct comments regarding this burden estimate or any aspect of this form to Dr. John
G. Dennis, Natural Resources (3127 MIB), National Park Service, 1849 C Street, N.W., Washington, DC 20240.

The National Park Service may not conduct or sponsor, and a person is not required to respond to, this collection of information unless it displays a currently valid
OMB control number.
(appformscif.doc; revised 04/13/2004) Page 2 of 3

APPLICATION FOR A SCIENTIFIC
RESEARCH AND COLLECTING PERMIT
United States Department of the Interior
National Park Service

OMB # (1024-0236)
Exp. Date (6/30/2007)
Form No. (10-741a)

If you are not using the automated system to prepare this application,
please fill out this form and return it to the appropriate park.
All or some of the information you provide may become available to the public.

Appendix A: Proposed Repository for Collected Specimens
A principal investigator has requested permission to collect specimens for permanent retention and has requested that the specimens
be loaned by the U.S. National Park Service to a repository that is not administered by the NPS. The principal investigator has been
instructed to obtain the signature of the repository official(s) as part of the permit application. The following information should be
completed and provided to the principal investigator. The principal investigator is responsible for ensuring the original signed form
(or fax of the signed form) is received by the appropriate Park Research Coordinator.
Principal Investigator:

Office phone #:
Office FAX #:
Office email address:

Project title (maximum 300 characters):

Scientific description of specimens proposed to be collected and loaned to the non-NPS institution identified below (include taxonomic group
or name, or type of material; sample size, quantity, frequency, and location):

Non-NPS institution where specimens identified in the box, above, are proposed to be deposited:
Organization Information
Institution: ________________________________________________________
Address:

________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

Office Phone #:
______________________________________________
Office FAX #:
______________________________________________
Responsible official Email:
_______________________________________________
This organization concurs with the proposal that collected specimens identified above be loaned to this institution for the purposes of
storage, management, and research subject to the “General Permit Conditions” and the terms of applicable National Park Service loan
agreements (available from the park).

________________________________________________
(Signature of responsible official at custodial institution)

____________________
(Date)

________________________________________________
(Name of responsible official – please print)

_________________________________________________
(Title of responsible official – please print)

The National Park Service may not conduct or sponsor, and a person is not required to respond to, this collection of information unless it displays a currently valid
OMB control number.
(appformscif.doc; revised 04/13/2004) Page 3 of 3