10-934 Application for Special Use Permit—Demonstrations and Di

NPS Form 10-934 (New Form 2023) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

APPLICATION FOR SPECIAL USE PERMIT DEMONSTRATIONS AND DISTRIBUTION OF MATERIALS [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. This application is only for those First Amendment activities regulated under 36 C.F.R. § 2.51 and 36 C.F.R. § 2.52; there are no fees or insurance required with this application. The National Park Service has up to 10 calendar days to respond to a complete application; allow sufficient time for the park to process your request. Applications may not be submitted more than one year before the proposed activity including time required for set up. You will be notified of the status of the application and the necessary steps to secure your final permit.

Applicant Information	Company/Organization Information
Applicant Name:	Company/Organization Name:
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

Some Activities may require additional information.

Have you visited the requested area? Yes No

Is this a First Amendment Activity as defined in 36 C.F.R § 2.51 or 36 C.F.R § 2.52? Yes No

Do you have, or are you applying for, a permit with another Federal, state, or local agency

for this activity? 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 or other message bearing items? Yes No

Do you intend to use audio amplification or generators? Yes No

Do you intend to use stages, platforms, or structures? Yes No

Do you intend to solicit donations or offer items for sale? 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.)

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/Organization 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. If you have checked the box that this is an exercise of a First Amendment activity under 36 C.F.R § 2.51 or 36 C.F.R § 2.52, there are no fees or insurance required with this application and no Social Security or Tax Identification Number is needed. 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

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.

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.

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-1.

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

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)