10-933 Application for Special Use Permit - Vehicle/Watercraft

NPS Form 10-933 (Rev. 08/2019)
National Park Service

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

APPLICATION FOR SPECIAL USE PERMIT
VEHICLE/WATERCRAFT USE
[PARK NAME]
[Street Address]
[City, State, Zip Code]
[Phone Number for Park Permits POC]

Type of Permit
Off-Road vehicle
Commercial vehicle access
Applicant Name (last, first, middle initial, suffix)

Snowmobile
Vehicle parking
Telephone Number

Company

Watercraft
Cell Phone Number

Address (Street address/P.O. Box, City, State, Zip Code)

Social Security Number or Tax ID number

Driver’s License Number

Issuing State

Email Address

Exp. Date

Year Round Resident?
Yes
No

Additional Driver’s (Limit of ____ drivers, attach additional pages, if necessary)
Name
Driver’s License Number

Issuing State

Emergency Point-of Contact Name

Exp. Date

Contact Phone Number
VEHICLE INFORMATION

Type of Vehicle
Passenger car

Van/light truck

Utility van/truck

Snowmobile
ATV/UTV
Vehicle Identification Number (VIN)

RV/camper/trailer

Bus

Semi/18-wheeler
Oversized load
Watercraft
License Plate/Registration Number Issuing State
Exp. Date

Year

Make

Model

Color

Weight

Length

Height

Number of Axels

Max. Number of Passengers

4-Wheel Drive Vehicle
Yes
No

(check one)

Inboard

Outboard

Watercraft motor(s)
Number of Motors

Horsepower (each)

VEHICLE INSPECTION INFORMATION
Is your vehicle required to undergo State inspections?
Company Name

Permit duration
Seven day

Yes

No

If “Yes”, expiration date:

VEHICLE INSURANCE INFORMATION
Policy Number (attach copy of valid insurance card)
PERMIT REQUEST DETAILS
Annual

Day use

Overnight

Start Date

Requested Use Area or Route

Other:

BUSINESS INFORMATION (if applicable)
Provide business name
Contractor

(select type of business below)

Sanitation/refuse

Plumbing

Electrical

HVAC

Delivery
Transportation (bus, taxi, etc.)
Public utility
Municipal
Other:
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.
Printed Name
Signature
Date
RECORDS RETENTION: TEMPORARY. Destroy/delete 3 years after closure. (NPS Records Schedule, Resource Management
and Lands (Item 1D) (N1-79-08-1))
508

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NPS Form 10-933 (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. OMB has approved this collection of information and assigned Control No. 1024-0026.

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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NPS Form 10-933 (Rev. 08/2019)
National Park Service

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

INTERNAL AGENCY USE ONLY
Project Number/BILL

Date Processed

Permit Number

Prepared By

Organization Name

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