Form 10-660A Monthly Report - Commercial Use Authorization

OMB Control No. 1024-XXXX

Exp. Date: XX/XX/2016

MONTHLY REPORT

COMMERCIAL USE AUTHORIZATION

DEPARTMENT OF THE INTERIOR

NATIONAL PARK SERVICE

PARK NAME

NAME, CUA COORDINATOR

COORDINATOR PHONE NUMBER

Due by <due date>

NOTE: This form is only to be used for monthly statistical reporting. A separate Annual Report is required for all CUAs.

1. Contact Information (as it appears on your permit)

Holder Name: _______________________ Contact Person (if different):___________________

Business Name: ______________________ Email(business) ____________________________

Mailing Address: _______________________ Email: (Contact Person) ______________________

_____________________________________ Phone: ____________________________________

2. Services Provided (as stated in your permit):

____________________________________________________________________________

VISITOR USE INFORMATION

3. How many clients did you serve within the park?

How many trips did your company make to the Park this month?

Enter the number of visitors who use your service in the format and detail required by the park.

Use the table below to report total numbers for the appropriate month. Report guide visits separately. Depending on the service provided, the chart below can be altered to fit the information requirements of the park.

(see attached Sample Tables for Monthly Reporting)

INJURY INFORMATION

4. Did you have any reportable injuries occur during your trips this month? Yes_____ No_____

If yes, please use a separate sheet of paper to report the date and type of injury and a brief statement of the incident and the outcome of the patient care, please omit the patient’s name. A reportable injury involves any medical incident or injury requiring medical aid beyond Basic First Aid and/or when a request for medical aid/rescue assistance is made. Provide details of any reportable injuries incurred to you, your employees, or clients. You do not need to send in a report if you have already done so.

SIGNATURE

5. Signature of Business Owner or Authorized Agent: False, fictitious or fraudulent statements of representations made in this report may be grounds for denial or revocation of the Commercial Use Authorization and may be punishable by fine or imprisonment (U.S. Code, Title 18, Section 1001). All information provided will be considered in reviewing this report. Authorized Agents must attach proof of authorization to sign below.

By my signature, I hereby attest that all my statements and answers on this form and any attachments are true, complete, and accurate to the best of my knowledge.

           

Signature Date

     

Printed Name

     

Title

PAPERWORK REDUCTION ACT STATEMENT: In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), please note the following. This information collection is authorized by The Concession Management Improvement Act of 1998 (16 U.S.C. 5966). Your response is required to obtain or retain a benefit in the form of a Commercial Use Authorization. We will use the information you submit to evaluate your ability to offer the services requested and to notify the public what services you offer. We estimate that it will take approximately 45 minutes to prepare a monthly report, including time to review instructions, gather and maintain data, and complete and review the report. We may may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid Office of Management and Budget control number. You may submit comments on any aspect of this information collection, including the accuracy of the estimated burden hours and suggestions to reduce this burden. Send your comments to: Information Collection Clearance Officer, National Park Service, 1849 C Street NW, Mail Stop 2601, Washington, D.C. 20240.

ATTACHMENT A

Sample Tables for Monthly Reporting

RETAIL SALES: (Farmers Markets, Special Performances, Special Events)

Month	Number of Retail Transactions	Revenue
April
May
June
July
August
September
Total for Season

EQUIPMENT RENTAL:

Month	Canoes	Kayaks	Sailboards	Bikes	Misc	Revenue
January
February
March
April
May
June
July
August
September
October
November
December
TOTAL

GUIDED BACKCOUNTRY TRIPS:

Month	Number of Trips	Number of Visitors	Number of Guides1
January
February
March
April
May
June
July
August
September
October
November
December
Total

¹ The number of times the guides led trips. If there are 2 guides on each trip and 5 trips the number of guides is 10

GUIDED HIKING:

Commercial Use Authorization National Park Service PARK
CUA Contact Phone				Monthly Activity Summary				Business: Phone:
Begin Date	End Date	(3)Total Days	(4) # of Clients	(5) # of Guides	(6) Total People (4+5)	(7) User Days (6*3)	Activity	Description of Trip Sample: Compton Trailhead to _______ and return
Total

MULTIPLE GUIDED ACTIVITIES:

Monthly Visitor Use Statistics
Business Name
	Year: 2013	Month:
Date of trip	Number of trips per day	Total number of people per day
1
2
3
4
5
6
7
8~31
TOTAL	0	0

NPS Form 10-660A, Rev. 05/2013