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

NPS Form 10-930s (Rev. 08/2019)
National Park Service

OMB Control No. 1024-0026
Expiration Date XX/XX/20XX

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

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:
Have you visited the requested area?
Yes
No

Cell Phone Number

Is this an exercise of a First Amendment rights?
Yes
No

Country

NPS Form 10-930s (Rev. 08/2019)
National Park Service

OMB Control No. 1024-0026
Expiration Date XX/XX/20XX

[Parks may remove the hunting sections below if not needed]
Hunting Season
Type of Weapon
Bow/Arrow
Rifle
Muzzleloader
Deer
Turkey
Boar/Hog/Javelina
Exotic Sheep
Shotgun
Other:
Small Game (rabbit, dove, quail, duck, etc.)
Other:
State Hunting License No. or
Driver’s License No.
State Fish and Game Customer Identification 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
[Insert Dates]
[Insert Dates]
[Insert Dates]
[Insert Dates]

Signature

Priority

Arrival Date

Departure Date

[Insert Date]
[Insert Date]
[Insert Date]
[Insert Date]

[Insert Date]
[Insert Date]
[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.

Date

INTERNAL AGENCY USE ONLY
Project Number/BILL

Date Processed

Permit Number

Prepared By

Organization Name
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NPS Form 10-930s (Rev. 08/2019)
National Park Service

OMB Control No. 1024-0026
Expiration Date XX/XX/20XX

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: 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 System of Records Notices Special Use Permits –Interior, NPS—1 (79 FR 9272).

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, 1201 Oakridge Drive, Fort Collins, CO 80525. Please do not
send your form to this address.

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