Form 10-930 Application for Special Use Permit

NPS Form 10-930 (Proposed Revision 2023) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

APPLICATION FOR SPECIAL USE PERMIT [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 non-refundable application fee of [insert amount] must accompany this application. 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 Information	Company/Organization Information
Applicant Name:	Company/Organization Name:
Social Security Number*:	Tax Identification Number*:
Street Address:	Street Address:
City:	City:
State:	State:
Zip Code:	Zip Code:
Country:	Country:
Telephone Number:	Telephone Number:
Cell Phone Number:	Contact Name:
Fax Number:	Fax Number:
Email Address:	Email Address:

Activity Details

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

Location Details

Requested Location

Equipment Details

Support equipment (list all equipment; attach additional pages if necessary)

Timing

Set-Up Begins	Activity Begins	Activity Ends	Removal Completed
Date: Time: AM PM	Date: Time: AM PM	Date: Time: AM PM	Date: Time: AM PM
Date: Time: AM PM	Date: Time: AM PM	Date: Time: AM PM	Date: Time: AM PM
Date: Time: AM PM	Date: Time: AM PM	Date: Time: AM PM	Date: Time: AM PM

Vehicles & Participants

If using any vehicles, attach a parking plan to this form.

Type	Maximum Number
Participants (best estimate)
Cars
Vans/Light Trucks
Utility Vans/Trucks
Buses/Oversized Vehicles

Support Personnel

List support personnel including addresses and telephones; attach additional pages if necessary.

Name	Address	Cell Phone Number

Individual in Charge

Individual in charge of activity onsite who is authorized to make decisions related to the permitted activity.

Name	Cell Phone Number

Activity Questions

Have you visited the requested area? Yes No

Do you plan to advertise or issue a press release before the event? Yes No

Have you obtained a permit from the National Park Service in the past? Yes No

(If yes, provide a list of permit dates and locations on a separate page.)

Will you distribute printed material? Yes No

Is there any reason to believe there will be attempts to disrupt, protest or prevent your event? Yes No

(If yes, please explain on a separate page.)

Do you intend to solicit donations or offer items for sale? Yes No

(These activities may require an additional permit.)

Is this permit to carry out a Good Samaritan Search and Recovery Mission? Yes No

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.

Name
Title
Company Name
Date
Signature

NOTICES

IMPORTANT NOTICE TO APPLICANT

This application does not serve as permission to conduct any special use activity in the Park. The information provided will be used to evaluate whether a permit will be issued. All applicable parts of the form must be completed. Incomplete applications will not be evaluated. Send the completed application, along with the application fee in the form of a [park to select payment methods accepted: cash, cashier’s check, money order, personal check]. Checks made payable to the National Park Service and all funds must be in US Dollars to [input name/park office and address]. Fees also may be paid online by credit card or electronic funds transfer at pay.gov. The application must be signed and dated in order for the application to be considered complete.

Purposes The purposes of this application are (1) to provide a National Park Service (NPS) 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 Title 5 U.S.C. § 552(a)(b) of the Privacy Act, records or information contained in this system may be disclosed outside the NPS as a routine use pursuant to Title 5 U.S.C. § 552(a)(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

If your request is approved, a permit containing applicable terms and conditions will be sent to 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.

PAPERWORK REDUCTION ACT STATEMENT

We are collecting this information subject to the Paperwork Reduction Act (Title 44 U.S.C. § 3501) to provide the Park Superintendent information needed to evaluate whether a permit will be issued for the requested use. 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. The authority to collect information on the attached form is derived from Title 31 U.S.C. § 7701. Taxpayer identifying number, Title 54 U.S.C. § 100101, Promotion and regulation; Title 54 U.S.C. § 100751, Regulations; Title 54 U.S.C. § 103104, Recovery of costs associated with special use permits; and Title 54 U.S.C § 100905 Commercial filming.

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, 13461 Sunrise Valley Drive Reston, Virginia 20192. Please do not send your application to this address.

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. All information collected using this form will be safeguarded in accordance with established regulations and published notices of System of Records, NPS

Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b): The collection of your SSN or TIN is necessary to allow the NPS to collect fees under Title 54 U.S.C.§ 103104 and Title 54 U.S.C. §100905. Your SSN or TIN will only be used as necessary to: (1) process this application, (2) collect any associated permit fees, and (3) collect and report any delinquent financial obligations. Failure to disclose your SSN or TIN when required may prevent or delay the processing of your application and issuing the associated permit. Use of your SSN or TIN will be carried out in accordance with established regulations and published notices of system of records, NPS-1

Effects of Nondisclosure: Failure to provide the requested information may impede your ability to obtain a permit from the NPS. 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 denying you a Special Use Permit.

INTERNAL AGENCY USE ONLY

Project Number/BILL:

Date Processed:

Permit Number:

Prepared By:

Organization Name:

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RECORDS RETENTION: Unapproved (3 years).  Maintain Approved applications with related permit and associated records based on appropriate item(s) in NPS Records Schedule 1, Resources Management and Lands, (N1-79-08-1)