Form 10-930s 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.

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

Proposed activity: __________________________________________________________________

Preferred Date	Preferred Location	Preferred Time
Alternate Date(s)	Alternate Location(s)	Alternate Time(s)

Alternatives will be considered if first choice is not available.

Maximum Number of Participants ____________ Maximum Number of Vehicles _____________

List of equipment (i.e. tables, chairs, grills, sound system, etc.)

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

________________________________________________________________________

Have you visited the requested area? Y N

Is this an exercise of a First Amendment rights? Y N

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 false statements have been given.

Signature: ___________________________________ Date: _____________________

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 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 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: $_______

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 15 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 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 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 matter within its jurisdiction.

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

Expires xx/xx/xxxx