Form 10-930 Application for Special Use Permit

National Park Service

(NPS site name)

(street, city state, zip code)

(telephone number)

Application for Special Use Permit

Please supply the information requested below. Attach additional sheets, if necessary, to provide required information. A nonrefundable processing fee of $xxx.xx must accompany this application unless the requested use is an exercise of a First Amendment right. You must allow sufficient time for the park to process your request; check with the park for guidelines. You will be notified of the status of the application and the necessary steps to secure your final permit. Your permit may require the payment of cost recovery charges and proof of liability insurance naming the United States of America as also insured.

Enter either a social security number OR a tax ID number: we do not require both.

Applicant Name:	Company/Organization Name:
Social Security #:	Tax ID #
Street/Address:	Street/Address:
City/State/Zip Code:	City/State/Zip Code:
Telephone #:	Contact name:
Cell phone #:	Telephone #:
Fax #:	Fax#:
Email:	Email:

Description of Proposed Activity (attach diagram, attach additional pages if necessary):

Requested Location(s): ______________________________________________________________________

DATE(S)

Set up begins: (date and time)	Activity begins: (date and time)	Activity ends: (date and time)	Removal completed (date and time)

Maximum Number of Participants (Please provide best estimate)

Maximum Number of vehicles: (attach parking plan)

_______Cars _______Vans/lt.trucks _______Utl.vans/trucks _______Buses/oversized vehicles

S upport equipment (list all equipment; attach additional pages if necessary)

List support personnel including addresses and telephones; attach additional pages if necessary

Individual in charge of activity on-site (include cell phone number) and authorized to make decisions related to the permitted activity:

Is this an exercise of First Amendment Rights? Y N

Have you visited the requested area? Y N

Have you obtained a permit from the National Park Service in the past? Y N

(If yes, provide a list of permit dates and locations on a separate page.)

Do you plan to advertise or issue a press release before the event? Y N

Will you distribute printed material? Y N

Is there any reason to believe there will be attempts to disrupt, protest or

prevent your event? (If yes, please explain on a separate page.) Y N

Do you intend to solicit donations or offer items for sale?

(These activities may require an additional permit.) Y N

You are encouraged to attach additional pages with information useful in evaluating your permit request including: staging, sound systems, parking plan, security plans, sanitary facilities, crowd control, emergency medical plan, use of any building, site clean-up, etc.

The applicant by his or her signature certifies that all the information given is complete and correct, and that no false or misleading information or statements have been given.

Signature Date ­­­___________________

Printed Name_________________________________ Title_______________________

Note: This is an application only, and does not serve as permission to conduct any special activity in the park. The information provided will be used to determine whether a permit will be issued. Send the completed application along with the application fee in the form of a credit card payment, cashier’s check, money order or personal check made payable to National Park Service to ___________________________________ at the Park address found on the first page of this application.

If your request is approved, a permit containing applicable terms and conditions will be sent you. The permit must be signed by the responsible person and returned to the park for final approval by the Park Superintendent before the permitted activity may begin.

Credit Card Authorization:  All credit card information is protected under the Privacy Act. Name as it appears on the card (print clearly):  _________________________________________

(Circle One): VISA MasterCard Discover

No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Exp. _ _ / _ _        Security Code _ _ _ _

(Month/Year)        

Total Amount Authorized: $XXX.00

Notice to Customers Making Payment by Personal Check: When you provide a check as payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day we receive your payment, and you will not receive your check back from your financial institution.

NOTICES

Privacy Act Statement: The Privacy Act of 1974 (5 U.S.C. 552a) provides that you be furnished with the following information in connection with information required by this application. This information is being collected to allow the park manager to make a value judgment on whether or not to allow the requested use. Applicants are required to provide their social security or taxpayer identification number for activities subject to collection of fees and charges by the National Park Service (31 U.S.C. 7701). Information from the application may be transferred to appropriate Federal, State, and local agencies, when relevant to civil, criminal or regulatory investigations or prosecutions.

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to provide the park managers the information needed to decide whether or not to allow the requested use. All applicable parts of the form must be completed in order for your request to be considered. You are not required to respond to this or any other Federal agency-sponsored information collection unless it displays a currently valid OMB control number.

Estimated Burden Statement: Public reporting burden for this form is estimated to average 30 minutes per response including the time it takes to read, gather and maintain data, review instructions and complete the form. Direct comments regarding this burden estimate or any other aspect of this form to the Information Collection Clearance Officer, National Park Service, 1849 C Street NW. (1237), Washington, D.C. 20240

Title 18 U.S.C. Section 1001 makes it a crime for any person to knowingly and willfully make to any department or agency of the United States any false, fictitious, or fraudulent statements or representations as to any mater within its jurisdiction.

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NPS Form 10-930 REV 06/2013 OMB Control No. 1024-0026

Expires xx/xx/xxxx