Form 10-357A Business Organization Information (Corporation, Limited

NPS Form 10-357A (Rev. 08/2016) OMB Control No. 1024-0029

National Park Service Expiration Date: ##/##/####

BUSINESS ORGANIZATION INFORMATION

Corporation, Limited Liability Company, Partnership, or Joint Venture

(Principal Selection Factor 3)

Note: Either a Form 10-357A or Form 10-357B is completed for each proposal, depending on the nature of ownership of the company.

Complete separate form for the submitting business entity and any and all parent entities.

Name of Entity and Trade-name, if any	     
Address	     
Telephone Number	     
Fax Number	     
Email Address	     
Contact Person	     
Title	     
Tax ID#	     
State of Formation	     
Date of Formation	     

Ownership	Percentage of Ownership Interests	Current Value of Investment
Names and Addresses of those with controlling interest and key principals of business	     	     
Total Interests Outstanding and Type(s):	     	     

Officers and Directors or General Partners or Managing Members or Venturers	Address	Title and/or Affiliation
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     

Attach the following:

• Description of relationship of any Offeror-Guarantor to the Offeror with respect to funding and management.

NOTICES

PRIVACY ACT STATEMENT

Authority: 16 U.S.C. 5966, Commercial Use Authorizations.

Purpose: The purposes of the system are (1) to assist NPS employees in managing the NPS Commercial Services program allowing commercial uses within a unit of the National Park System to ensure that business activities are conducted in a manner that complies with Federal laws and regulations; (2) to monitor resources that are or may be affected by the authorized commercial uses within a unit of the National Park System; (3) to track applicants and holders of commercial use authorizations who are planning to conduct or are conducting business within units of the National Park System; and (4) to provide to the public the description and contact information for businesses that provide services in national parks.

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 DOI as a routine use pursuant to 5 U.S.C. 552a(b)(3) to other Federal, state and local governments, tribal organizations, and members of the general public upon request for names, addresses and phone numbers of Commercial Use Authorizations (CUA) holders conducting business within units of the National Park System for the purpose of informing the public of the availability of the services offered by the CUA holder. In addition, records or information contained in this system may be disclosed outside DOI 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 our ability to 1) manage the National Park Service (NPS) Commercial Services Program allowing commercial uses within a unit of the NPS, 2) monitor resources that are or may be affected by the authorized commercial uses, and 3) provide the public the description and contact information for businesses that provide services in national parks.

PAPERWORK REDUCTION ACT STATEMENT

We collect this information under the authority of Title IV of the National Parks Omnibus Management Act of 1998 (Pub. L. 105–391). We use this information to evaluate a concession proposal. Your response is required to obtain or retain a benefit. We may not collect or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB control number. OMB has approved this collection of information and assigned Control No. 1024-0029.

ESTIMATED BURDEN STATEMENT

We estimate that it will take you 1 hour to complete this form, including time to review instructions, gather and maintain data, and complete and review the form. You may send comments on the burden estimate or any aspect 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 completed form to this address.

RECORDS RETENTION. TEMPORARY. Destroy/Delete 3 years after closure. (NPS Records Schedule, Commercial Visitor Services, (Item 5D)

(N1-79-08-4))