Form 10-930s Application for Special Use Permit (Short Form)

NPS Form 10-930s (Rev. 07/2016) OMB Control No. 1024-0026

National Park Service Expiration Date XX/XX/2019

APPLICATION FOR SPECIAL USE PERMIT

SHORT FORM

[PARK NAME]

[Street Address]

[City, State, Zip Code]

[Phone Number for Park Permits POC]

Please supply the information requested below. Attach additional sheets, if necessary, to provide required information. A nonrefundable processing fee of [insert amount] 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 an additional insured.

Applicant Name			Telephone Number
     			     
Organization			Cell Phone Number
     			     
Social Security Number or Tax ID number			Fax Number
     			     
Email Address
     
Street Address
     
City					State	Zip Code	Country
     					     	     	     
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
     
Individual in charge of activity onsite who is authorized to make decisions related to the permitted activity:				Cell Phone Number
     				     
Have you visited the requested area?		Is this an exercise of a First Amendment rights?
Yes No		Yes No

[Parks may remove the hunting sections below if not needed]
Hunting Season			Type of Weapon
Deer Turkey Boar/Hog/Javelina Exotic Sheep Small Game (rabbit, dove, quail, duck, etc.) Other:      			Bow/Arrow Rifle Muzzleloader Shotgun Other:      
State Hunting License No. or State Fish and Game Customer Identification No.			Driver’s License No. (If Different from Hunting License No.)				State Issued
     			     				     
Permit Confirmation Number (if purchased online)
     
There are a total of [Insert #] weeks of [Insert type of Hunting Season] hunting that will be allowed in [Insert Park Name]. You may prioritize the order of your preference for the [Insert #] weeks to be considered in the spaces provided below. Number your priority for selection utilizing the numbers 1-[Insert #]. The dates of the weeks are scheduled as follows:
Week	Priority		Arrival Date	Departure Date
[Insert Dates]	     		[Insert Date]	[Insert Date]
[Insert Dates]	     		[Insert Date]	[Insert Date]
[Insert Dates]	     		[Insert Date]	[Insert Date]
[Insert Dates]	     		[Insert Date]	[Insert Date]
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

NOTICES

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 [park to select payment methods accepted: credit card payment, cashier’s check, money order or personal check made payable to the National Park Service] to [input name/park office] 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.

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.

Privacy Act Statement

Authority: 16 U.S.C. 1, National Park Service Organic Act; 16 U.S.C. 3, Rules and regulations of national parks, reservations, and monuments; timber; leases, 16 U.S.C. 3a, Recovery of costs associated with special use permits; and 16 U.S.C. 460i–6d, Commercial Filming.

Purpose: The purposes of the system are (1) to provide a park superintendent with information to approve or deny requests for activities that provide a benefit to an individual, group or organization, rather than the public at large; and (2) to assist park staff to manage the activity to ensure that the permitted activity does not interfere with the enjoyment of the park by visitors and that the natural and cultural resources of the park are protected.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C.552a(b) of the Privacy Act, records or information contained in this system may be disclosed outside the National Park Service as a routine use pursuant to 5 U.S.C. 552a(b)(3) to other Federal, State, territorial, local, tribal, or foreign agencies and other authorized organizations and individuals based on an authorized routine use when the disclosure is compatible with the purpose for which the records were compiled as described under the system of records notice for this system.

Disclosure: Voluntary, however, failure to provide the requested information may impede individual from obtaining a permit from the National Park Service.

Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b): Your Social Security Number (SSN) is needed to identify records unique to you. 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. Failure to disclose your SSN may prevent or delay the processing of your application. The authority for soliciting your SSN is 31 U.S.C. 7701. The information gathered through the use of the SSN will be used only as necessary for processing this application and collecting and reporting any delinquent financial obligations. Use of the social security number will be carried out in accordance with established regulations and published notices of system of records.

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 aspects of this form, to the Information Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Drive, Mail Stop 242, Reston, VA 20192. Please do not send your form to this address.

Credit Card Authorization

All credit card information is protected under the Privacy Act of 1974

Applicant Name

Cardholder Name (as it appears on card)

     

     

Same as “Applicant”

Company Name (if applicable)

Telephone Number

Cell Phone Number

     

     

Email Address

Federal Taxpayer Identification or Social Security Number

     

     

Credit Card Billing Address

     

City

State

Zip Code

Country

     

     

     

     

Amount to be Billed to Card

Application Cost $     

Location Fee $     

Cost Recovery $     

Total $     

Type of Credit Card

Credit Card Number

Expiration Date

Security Code

American Express

Discover

Mastercard

Visa

     

     

     

I hereby authorize my card to be charged the amount indicated above in connection with the issuance of the requested Special Use Permit:

Cardholder Authorized Signature

Date

     

INTERNAL AGENCY USE ONLY

Project Number/BILL	Date Processed
     	     
Permit Number	Prepared By
     	     
Organization Name
     

RECORDS RETENTION: TEMPORARY. Destroy/delete 3 years after closure. (NPS Records Schedule, Resource Management Page 5 of 11

and Lands (Item 1D) (N1-79-08-1))