Form 10-932 Application for Special Use Permit--Commercial Filming/S

National Park Service

(NPS site name)

(street, city state, zip code)

(telephone number)

Application for Special Use Permit

Commercial Filming/Still Photography

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:	Applicant Company:
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:

Project name:	Telephone #:
Location manager:	Cell phone #:
	Email:

TYPE OF PROJECT:  Still photography  video/motion picture/film

Detailed description of onsite activities: (attach additional pages as necessary)

LOCATION SCHEDULE:

Each date and each location must have an individual entry – use additional pages as necessary.

DATE	LOCATION	Start Time	End Time	Interior or Exterior	Activity: Set-Up/ Film / Non-Filming /Breakdown	# of cast & crew*

*number in this column should include all individuals present at the location

Talent comprises anyone in front of the camera and includes, but is not limited to, actors, hosts, correspondents, presenters, park visitors, cooperators, volunteers, National Park Service and concessioner staff, etc.

Do you intend to utilize talent?  Yes  No

If yes, provide a full description of who they are and how they will be utilized:

Description of equipment including backdrops, sets, props, etc., to be added to or constructed on park lands: ________________________________________________________________________________

_____________________________________________________________________________________

ELECTRICAL REQUIREMENTS: (explain) __________________________________________________

____________________________________________________________________________________

Generator(s):  No  Yes, quantity _________ size _______________

Lighting:  None  Reflectors only  Yes

Explain: ___________________________________________________

Road Use: Date/time: ________________________

Road closure requested?  No  Yes

Driving shots  Drive-bys  Tow shots  Drive-ups & Away  Wet down road

Camera/Equipment on Road Shoulder  Camera/Equipment on median  Other (explain) _______________________________________________________________________________

_________________________________________________________________________________

CAMERAS (check all that apply)

Hand ___ Tripod___ Dolly___ Dolly w/track footage ___ Crane or jib arm ___ Arm footage ___

Portable crane___ Car mount ___ Camera car, shot maker, or process trailer ___

OPERATIONAL INFORMATION:

Vehicles:

Number of Cars, SUVs or light pick-up trucks ____________

Number of Vehicles greater than a 10,000 lbs. (class 3 or higher)__________________

NOTE: Large or oversized vehicles may not be able to be accommodated or additional steps may need to be taken to ensure that no damage to park resource occurs.

BASE CAMP LOCATION: (attach diagram): ____________________________________________

SPECIAL ACTIVITIES

INVOLVEMENT OF MINORS:

Children:  None  Yes # of Children Age Range ______________________

LIVESTOCK and/or TRAINED ANIMALS:

Number and type of animal: _______________ Manner of transportation: _____________________

Staging/corralling needs (attach plan if necessary):_______________________________________

A IRCRAFT:  No  Yes (explain)

NOTE: All aircraft use over park lands should be listed. Landings must be specifically requested and approved as a condition of your permit.

SPECIAL EFFECTS (including weapons, pyrotechnics, etc):  No  Yes (identify)

Effects Technician Name: Phone # ____________________________

License # (if applicable) Permit # (if applicable) ________________

STUNTS:  No  Yes (explain)

Coordinator­­­­­­­­­­­­­­­­­­­­­­­ _______________________Phone #________________ Email_____________________

Any other unusual or hazardous activities?  No  Yes (explain)

Have you physically visited the requested area? Y N

When answering yes to any of the following questions, provide additional information:

Do you have, or are you applying for, a permit with another Federal, State or local

agency for this activity YN

Have you had previous permits from the National Park Service? YN

Have you ever been denied a permit or had a permit revoked? Y N

Have you forfeited a bond or other security for filming on Federal lands? Y N

Are there any pending investigations against you which involve a commercial Y N

filming permit

Do you plan to advertise or issue a press release about this activity? Y N

Do you anticipate any security concerns? If yes, explain. Y N

You are encouraged to attach additional pages with information useful in evaluating your permit request including: story boards or scripts, set construction, parking plan, security plans, sanitary facilities, crowd control, emergency medical plan, off-road activity, trail use, use of any building and site clean-up.

PROJECT ADMINISTRATION:

Are you applying for this permit on behalf of another person or company? Y N

If yes, provide a full description (including contact information) of all other individuals/companies involved

with this project (attach additional sheets if needed):

CONTACTS:

Person on location responsible for adherence to all terms & conditions of the permit:

Name: ________________________________ Title: ___________________________

Phone: _______________ Cell Phone: _________________ Email: __________________________

Person on location responsible for coordinating activities with the NPS:

Name: ________________________________ Title: ___________________________

Phone: _______________ Cell Phone: _________________ Email: __________________________

Person at the company office to contact for follow up information and billing:

Name: ___________________________Title: _________________________Phone: _____________

Email: ________________________

I hereby state that the above information given is complete and correct, and that no false or misleading information or false statements have been given. All estimates are reliable to the best of my knowledge and I have the full authority to represent the applicant/production company and the project described above.

Signature ______________________________ Title _____________________ Date ____________

Company Name _________________________________________________________

******************************************************************************

Note: this is an application only, and does not serve as permission to conduct 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 cashier’s check or money order 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 to the person designated on the application. The permit must be signed by the responsible person and returned to the park for final approval by the Park Superintendent.

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: $________

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 in 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 aspects 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 knowingly and willfully to 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.

NPS Form 10-932 rev 06/2013 OMB Control No. 1024-0026

Expires xx/xx/20xx