Form 10-741b Application for a Science Education Permit

APPLICATION FOR A SCIENCE EDUCATION PERMIT

United States Department of the Interior

National Park Service

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 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)
[Dr., Mr., Mrs., Ms.] First name: Last name:					Office phone #:
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 Initial starting date of the activity: ________ Estimated date the entire activity may end: ________			Field Schedule Date to begin activity within the park this application year: ____________ Date to end activity within the park this application year: ____________ Number of times the field activity will be conducted this application year: __________ 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 this National Park System area:
Your proposed method of access (bus, van, car, other vehicle, aircraft, boat, snowmobile, foot, other):
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: _____________________ Date: _________________________
For National Park Service use only	Date received	Assigned activity number				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 form is estimated to average 1.0 hour 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 (3130 MIB), National Park Service, 1849 C Street, N.W., Washington, DC 20240.

Privacy Act Notice: Scientific research, education and collecting activities within units of the National Park System that may impact parks invoke a permitting and reporting requirement per regulations at 36 CFR 1.6 (Permits), 36 CFR 2.1 (Preservation of Natural, Cultural and Archeological Resources), and 36 CFR 2.5 (Research Specimens). The National Park Service collects information about permit applicants and permittees to administer and document research, collecting, and reporting activities within parks. The information disclosed on this form is required and may result in denial of permit applications if not provided.

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. (appformedu.doc; revised 11/2/2010) Page 2 of 2