Form 10-930 Application of Special Use Permit

NPS Form 10-930 (Rev. 06/2016) OMB Control No. 1024-0026

National Park Service Expiration Date XX/XX/2019

APPLICATION FOR SPECIAL USE PERMIT

[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.

* Enter either a Social Security Number OR a tax ID number; we do not require both.

Applicant Name

Company/Organization Name

     

     

Social Security Number*

Tax Identification Number*

     

     

Street Address

Street Address

     

     

City

State

Zip Code

Country

City

State

Zip Code

Country

     

     

     

     

     

     

     

     

Telephone Number

Contact Name

     

     

Cell Phone Number

Telephone Number

     

     

Fax Number

Fax Number

     

     

Email Address

Email Address

     

     

Description of Proposed Activity (attach diagram and/or additional pages, if necessary)

     

Requested Location

     

Set-Up Begins

Activity Begins

Activity Ends

Removal Completed

Date      

Date      

Date      

Date      

Time       AM PM

Time       AM PM

Time       AM PM

Time       AM PM

Date      

Date      

Date      

Date      

Time       AM PM

Time       AM PM

Time       AM PM

Time       AM PM

Date      

Date      

Date      

Date      

Time       AM PM

Time       AM PM

Time       AM PM

Time       AM PM

Maximum Number of Participants (Best Estimate)

Maximum Number of Vehicles (attach parking plan)

Cars

Vans/Light Trucks

Utility Vans/Trucks

Buses/Oversized Vehicles

     

     

     

     

     

Support equipment (list all equipment; attach additional pages if necessary)

     

List support personnel including addresses and telephones; attach additional pages if necessary

Name

Address

Cell Phone Number

     

     

     

     

     

     

     

     

     

Individual in charge of activity onsite who is authorized to make decisions related to the permitted activity:

Cell Phone Number

     

     

Is this an exercise of First Amendment Rights?

Yes No

Have you visited the requested area?

Yes No

Have you obtained a permit from the National Park Service in the past? (If yes, provide a list of permit dates and locations on a separate page.)

Yes No

Do you plan to advertise or issue a press release before the event?

Yes No

Will you distribute printed material?

Yes No

Is there any reason to believe there will be attempts to disrupt, protest or prevent your event? (If yes, please explain on a separate page.)

Yes No

Do you intend to solicit donations or offer items for sale? (These activities may require an additional permit.)

Yes No

You are encouraged to attach additional pages with information useful in evaluating your permit request including: staging, sound systems, parking plan, security plans, sanitary facilities, crowd control, emergency medical plan, use of any building, site clean-up, etc. 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 statements have been given.

Printed Name

Title

     

     

Signature

Date

     

NOTICES

IMPORTANT NOTICE TO APPLICANT

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

General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals completing this application.

Authority: The authority to collect information on the attached form is derived from Title 31, United States Code, Section 7701.

Purposes and Uses: The information being collected to allow the park manager to make a value judgment on whether or not to allow the requested use. Information from the application may be transferred to appropriate Federal, State, and local agencies, when relevant to civil, criminal or regulatory investigations or prosecutions.

Effects of Nondisclosure: It is in your best interest to answer all of the questions. The U.S. Criminal Code, Title 18 U.S.C. 1001, provides that knowingly falsifying or concealing a material fact is a felony that may result in fines of up to $10,000 or 5 years in prison, or both. Deliberately and materially making false or fraudulent statements on this form will be grounds for not granting you a Special Use Permit

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 (31 U.S.C. 7701). Although disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or delay the processing of your application. The authority for soliciting and verifying your SSN is Executive Order 9397. The information gathered through the use of the SSN will be used only as necessary for processing this application and 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 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, 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 Page 1 of 11

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