10-930c Application for Special Use Permit--Climbing - Private

NPS Form10- 930c (Rev. 08/2019)
National Park Service

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

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

The permittee is prohibited from giving false information; to do so will be considered a breach of conditions and be grounds for revocation of the
permit [36 CFR 2.32(a)(3)].

Party Information

Leader Name
Proposed Start Date

Proposed Completion Date

Make/Model

Color

Make/Model

Color

Party Size

Vehicle Information
License

State

License

State

Location Vehicle(s) Parked

Departure Date

Itinerary
Return Date

Route Up

Route Down

Night

1st Night

2nd Night

3rd Night

Party Size

4th Night

5th Night

Date
Camp

ISSUANCE of this permit is subject to the attached conditions. The undersigned acknowledges they have read the
attached conditions and hereby accepts this permit subject to the terms, covenants, obligations, and reservations,
expressed or implied herein.

PERMITTEE Signature
Authorizing NPS Official

Title:

Date:

Title:

Date:

NPS Form10- 930c (Rev. 08/2019)
National Park Service

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

PERMIT CONDITIONS
1. The following form MUST be returned to the National Park Service
Upon Return Complete this Form
Date Returned

Number to the Summit

2.

This permit may not be transferred or assigned without the prior written consent of the Superintendent.

3.

The permittee shall exercise this privilege subject to the supervision of the Superintendent or designee, and shall comply with all
applicable Federal, State, county and municipal laws, ordinances, regulations, codes, and the terms and conditions of this permit.
Failure to do so may result in the immediate suspension of the permitted activity or the revocation of the permit. All costs associated
with clean up or damage repairs in conjunction with a revoked permit will be the responsibility of the permittee.

5

The permittee is responsible for making all necessary contacts and arrangements with other Federal, State, and local agencies to
secure required inspections, permits, licenses, etc.

6

The park area associated with this permit will remain open and available to the public during park visiting hours. This permit does not
guarantee exclusive use of an area. Permit activities will not unduly interfere with other park visitors’ use and enjoyment of the area.

7

This permit may be revoked at the discretion of the Superintendent upon 24 hours notice.

8

The permit may be revoked without notice if damage to resources or facilities occurs or is threatened, notwithstanding any other term or
condition of the permit to the contrary.

9

This permit is made upon the express condition that the United States, its agents and employees shall be free from all liabilities and
claims for damages and/or suits for or by reason of any injury, injuries, or death to any person or persons or property of any kind
whatsoever, whether to the person or property of the permittee, its agents or employees, or third parties, from any cause or causes
whatsoever while in or upon said premises or any part thereof during the term of this permit or occasioned by any occupancy or use of
said premises or any activity carried on by the permittee in connection herewith, and the permittee hereby covenants and agrees to
indemnify, defend, save and hold harmless the United States, its agents, and employees from all liabilities, charges, expenses and
costs on account of or by reason of any such injuries, deaths, liabilities, claims, suits or losses however occurring or damages growing
out of the same.

10 The person(s) named on the permit as in charge of the permitted activity on-site must have full authority to make any decisions about
the activity and must remain on-site at all times. He/she shall be responsible for all individuals, groups, vendors, etc. involved with the
permit.
11 Nothing herein contained shall be construed as binding the Service to expend in any one fiscal year any sum in excess of
appropriations made by Congress or administratively allocated for the purpose of this permit for the fiscal year, or to involve the Service
in any contract or other obligation for the further expenditure of money in excess of such appropriations or allocations.
12 If any provision of this permit shall be found to be invalid or unenforceable, the remainder of this permit shall not be affected and the
other provisions of this permit shall be valid and be enforced to the fullest extent permitted by law.

Add Park Specific Conditions Sequentially

NPS Form10- 930c (Rev. 08/2019)
National Park Service

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

Party Members
Name

Emergency Contact Name/
Number

Past Summits / Routes

Payment Confirmation #

2.
3.
5.
6.
7.
8.
9.
10.
11.
12.

Personal and Team Equipment (Indicate the number of items)
____ Pickets

____ GPS

____ Days of Food

____ Pulleys

____ Altimeter

____ Wands

____ Prussiks

____ Radio (Type / Channel)

____ Avalanche Beacon

____ Ice Screws

____ Skis/Snowboards

____ Probe

____ Helmets

____ Tents ____ Color

____ Shovel

NPS Form10- 930c (Rev. 08/2019)
National Park Service

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

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 [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
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 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 make a value judgment on whether or not to allow the
requested use. 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: It is in your best interest to answer all of the questions. 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): 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 (31 U.S.C. 7701). Although disclosure of your SSN is not
mandatory, failure to disclose your SSN may prevent or delay the processing of your application. 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 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, 1201 Oakridge Drive, Fort Collins, CO 80525. Please do not send your form to this
address.