10-352 Form 10-352 Identification and Credit Information (Indiv

NPS Form 10-352 (08/2016) OMB Control No. 1024-0233

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

IDENTIFICATION AND CREDIT INFORMATION (INDIVIDUAL)

NPS Leasing Program

Commercial Services Division

1849 C Street, NW

Washington, DC 20240

I. IDENTIFICATION INFORMATION

Name

Telephone Number

Alternate Number

Email Address

     

     

     

Cell

     

Fax

Address

City

State

Zip Code

     

     

     

     

Education

Degrees

Licenses

Designations

Special Skills

     

     

     

     

     

Name of Current Employer

Title of Position Most Recently Held

Nature of Business

Dates of Employment

     

     

     

     

Address of Employment

City

State

Zip Code

     

     

     

     

Description of Duties and Responsibilities (Include number of people supervised)

     

Proposed Role in Lease Operations

Qualifications for that Role

Estimated Time per Week Dedicated to Role

     

     

     

II. CREDIT INFORMATION

1. List any Foreclosures, Bankruptcies, Transfers in Lieu of Foreclosure and/or Work-Out/Loan Modification Transactions during the past 10 years. (If none, so indicate). Attach an explanation of circumstances, including resolution, bankruptcy plan, and/or other documentation as appropriate.

     

2. Describe any fines or penalties levied by government agencies during the past 10 years. (If none, so indicate)

     

3. Describe any pending litigation or current lawsuits which if adversely resolved would materially impact the financial position of the Applicant.

     

4. Attach:

a. Personal Financial Statement documenting assets and liabilities.

b. Credit Reports for the individual(s) from a major credit reporting company such as Equifax, Experian, and Dunn & Bradstreet.

NOTICES

PRIVACY ACT STATEMENT

Authority: Title 54, National Park Service and Related Programs; and the National Environmental Policy Act of 1969.

Purpose: The purpose of the system is to assist, monitor, track and issue leases to individuals and businesses for National Park Service structures and land for activities that are not subject to authorization through a concession contract, commercial use authorization, or similar instrument in federally owned or administered property located within the boundaries of park areas. A leased property must be used for an activity and in a manner that is consistent with the purposes established by law for the park and be compatible with the programs of the National Park Service.

Routine Uses: Records or information contained in this system is not disclosed outside of the Department of the Interior except for those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act; or other authorized routine use when the disclosure is compatible with the purpose for which the records were compiled.

Disclosure: Voluntary, however, failure to provide the requested information may impede our ability to issue a lease contract to the individual or organization.

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 proposals received in response to leasing opportunities. 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. 1024-0233.

ESTIMATED BURDEN STATEMENT

We estimate that it will take you 10 hours to complete a standard Request for Proposal, including 2 hours 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))