Form 10-933 Application for Special Use Permit - Vehicle/Watercraft

NPS Form 10-933 (Rev. 06/2016) OMB Control No. 1024-0026

National Park Service Expiration Date XX/XX/2019

APPLICATION FOR SPECIAL USE PERMIT

VEHICLE/WATERCRAFT USE

[PARK NAME]

[Street Address]

[City, State, Zip Code]

[Phone Number for Park Permits POC]

Type of Permit

Off-Road vehicle

Commercial vehicle access

Snowmobile

Vehicle parking

Watercraft

Applicant Name (last, first, middle initial, suffix)

Telephone Number

Cell Phone Number

     

     

     

Company

Company Address (Street address/P.O. Box, City, State, Zip Code)

     

     

Social Security Number or Tax ID number

Driver’s License Number

Issuing State

Exp. Date

     

     

     

     

Email Address

     

Additional Driver’s (Limit of ____ drivers, attach additional pages, if necessary)

Name

Driver’s License Number

Issuing State

Exp. Date

     

     

     

     

     

     

     

     

Emergency Point-of Contact Name

Contact Phone Number

     

     

VEHICLE INFORMATION

Type of Vehicle

Passenger car

Van/light truck

Utility van/truck

RV/camper/trailer

Bus

Snowmobile

ATV/UTV

Semi/18-wheeler

Oversized load

Watercraft

Vehicle Identification Number (VIN)

License Plate/Registration Number

Issuing State

Exp. Date

     

     

     

     

Year

Make

Model

Color

Weight

     

     

     

     

     

Length

Height

Number of Axels

Max. Number of Passengers

4-Wheel Drive Vehicle

     

     

     

     

Yes No

Watercraft motor(s)

(check one) Inboard Outboard

Number of Motors      

Horsepower (each)      

VEHICLE INSPECTION INFORMATION

Is your vehicle required to undergo State inspections? Yes No If “Yes”, expiration date:      

VEHICLE INSURANCE INFORMATION

Company Name

Policy Number (attach copy of valid insurance card)

     

     

PERMIT REQUEST DETAILS

Permit duration

Start Date

Requested Use Area or Route

Seven day Annual Day use Overnight Other:      

     

     

BUSINESS INFORMATION (if applicable)

Provide business name       (select type of business below)

Contractor

Sanitation/refuse

Plumbing

Electrical

HVAC

Delivery

Transportation (bus, taxi, etc.)

Public utility

Municipal

Other:      

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.

Printed Name

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. OMB has approved this collection of information and assigned Control No. 1024-0026.

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