Form 10-741b APPLICATION FOR A SCIENCE EDUCATION PERMIT

APPLICATION FOR A SCIENCE EDUCATION PERMIT
United States Department of the Interior
National Park Service
OMB # (1024-0236)
Exp. Date (6/30/2007)
Form No. (10-741b)

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 activity number:
Previously assigned NPS permit number:

Contact information for the activity leader (responsible official)
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 responsible official:

Provide the first and last name of the person expected to back up the activity leader during visits to the park:

Proposed Science Education Activity Information
Name or title of proposed science education activity (maximum 300 characters)

Purpose and brief description of the activity (maximum 4000-characters)

Proposed field methods and activities (summarize from the proposal where appropriate – maximum 4000 characters)

Planned number of instructors and leaders: _____
Planned number of students: _____

Indicate educational levels of this activity (select all that apply):
K-6 _____
7-12 _____
Higher _____

Activity Schedule

Field Schedule

Date to begin activity within the park this application year: ____________
Initial starting date of the activity: ________
Date to end activity within the park this application year: ____________
Number of times the field activity will be conducted this application year: __________
Estimated date the entire activity may end: ________
Will the field activity need to continue within the park next year (Yes/No): ________
Do you anticipate seeking any waiver of fees or other NPS assistance in conjunction with this activity? (Yes or No):
If “Yes,” please explain:
Location(s) where you propose activities will take place within the National Park System area(s):

Your proposed method of access (bus, van, car, other vehicle, aircraft, boat, snowmobile, foot, other):

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.
(appformeduf.doc; revised 04/14/2004) Page 1 of 2

APPLICATION FOR A SCIENCE EDUCATION PERMIT
United States Department of the Interior
National Park Service
OMB # (1024-0236)
Exp. Date (6/30/2007)
Form No. (10-741b)

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 temporarily handle or collect specimens? (Yes or No)
If you respond "No," you will not be authorized to handle or collect specimens. Please skip to the Certification section of the application.
If you respond “Yes,” please complete the next section of the application before moving to the Certification 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):
A) Specimens to be handled and returned unmodified to the place of collection:

B) Specimens to be handled and used up in the activity:

Certification
I certify that this application is accurate and complete. I understand a formal science education activity proposal may have to 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 activity leader:
For National Park Service use only

_____________________
Date received

Assigned activity 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.
(appformeduf.doc; revised 04/14/2004) Page 2 of 2