Form 10-930 Application for Special Use Permit

NPS Form 10-930 (Rev. 06/2020)
National Park Service

OMB Control No. 1024-0026

Expiration Date TBD

APPLICATION FOR SPECIAL USE PERMIT
Longfellow House- Washington’s Headquarters NHS
105 Brattle Street
Cambridge, MA 01830
(617)876-4491
Please supply the information requested below. Attach additional sheets, if necessary, to provide required information. A
nonrefundable processing fee of $50.00 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

I

Zip Code

I

Country

City

I

State

I

Telephone Number

Contact Name

Cell Phone Number

Telephone Number

Fax Number

Fax Number

Email Address

Email Address

Zip Code

I

Country

I

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

RECORDS RETENTION: TEMPORARY. Destroy/delete 3 years after closure. (NPS Records Schedule, Resource Management and
Lands (Item 1D) (N1-79-08-1))

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NPS Form 10-930 (Rev. 06/2016)
National Park Service

OMB Control No. 1024-0026

Expiration Date 01/31/2020

Requested Location
Set-Up Begins
Date
Time
Date
Time
Date
Time

D

AM D PM

D

AM D PM

D

AM D PM

Maximum Number of
Participants (Best Estimate)

Activity Begins
Date
Time
Date
Time
Date
Time

Activity Ends

D

AM D PM

D

AM D PM

D

AM D PM

Date
Time
Date
Time
Date
Time

Removal Completed

D

AM

D

PM

D

AM

D

PM

D

AM

D

PM

Date
Time
Date
Time
Date
Time

D

AM

D

PM

D

AM

D

PM

D

AM

D

PM

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

D Yes
D Yes
D Yes
D Yes
D Yes
D Yes
D Yes

Is this an exercise of First Amendment Rights?
Have you visited the requested area?
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.)
Do you plan to advertise or issue a press release before the event?

D No
D No
D No
D No
D No
D No
D No

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

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NPS Form 10-930 (Rev. 06/2016)
National Park Service

OMB Control No. 1024-0026

Expiration Date 01/31/2020

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
cashier’s check, money order or personal check made payable to the National Park Service with ATTN: to Site Manager 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 necessary to recover any fees, charges or payment 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 evaluate the requests for special park use
permits. 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: In oder to provide sufficient information to validate your request for a permit, please answer all of the
questions. in the form to the best of your ability. 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) and 31 U.S.C 7701,
applicants are required to provide their social security or taxpayer identification number for activities subject to debt recovery or the
collection of fees and charges by the National Park Service. The disclosure of your SSN is not mandatory, however incomplete
applications may prevent or delay the process. 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 or collecting and
recovering a debt 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.

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NPS Form 10-930 (Rev. 06/2016)
National Park Service

OMB Control No. 1024-0026
Expiration Date 01/31/2020

INTERNAL AGENCY USE ONLY

Project Number/BILL

Date Processed

Permit Number

Prepared By

Organization Name

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