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| Question | Answer |
|---|---|
| Form Name | Nps Form 10 930 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | certifies, refundable, 552a, Utah |
NPS Form |
National Park Service |
OMB No. |
Southeast Utah Group |
NEW 10/00 |
2282 S. W. Resource Blvd. |
|
Moab, Utah 84532 |
Expires 6/30/2013 |
(435) |
Application for Special Use Permit
Please supply the information requested below. Attach additional sheets, if necessary, to provide required information. Allow AT LEAST 10 business days for processing (2 business days for First Amendment requests). A
Applicant Name: |
Organization Name: |
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Social Security #: |
Tax ID # |
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Street/Address: |
Street/Address: |
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City/State/Zip Code: |
City/State/Zip Code: |
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Telephone #: |
Telephone #: |
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Cell phone #: |
Cell phone #: |
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Fax #: |
Fax#: |
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Description of Proposed Activity (attach diagram, attach additional pages if necessary):
Requested Location:
Date(s):
Event set up will begin:
(date and time)
Event will begin: (date and time)
Event will end: (date and time)
Removal will be done:
(date and time)
Maximum Number of Participants |
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(Please provide best estimate) |
1
Maximum Number of Vehicles |
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(attach parking plan) |
Support Equipment (list all equipment; attach additional pages if necessary) |
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List support personnel (contractors, etc. including addresses and telephones attach additional pages if necessary)
Individual in charge of event on site (include address, telephone and cell phone numbers):
Is this an exercise of First Amendment Rights?
Are you familiar with/ have you visited the requested area?
Have your obtained a permit from the National Park Service in the past?
(If yes, provide a list of permit dates and locations on a separate page.) Do you plan to advertise or issue a press release before the event?
Will you distribute printed material?
Is there any reason to believe there will be attempts to disrupt, protest or prevent your event?(If yes, please explain on a separate page.)
Do you intend to solicit donations or offer items for sale? (These activities may require an additional permit.)
Y Y Y
Y Y
Y
Y
N N N
N N
N
N
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.
Signature |
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Date ___________________ |
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Information provided will be used to determine whether a permit will be issued. Completed application must be accompanied by an application fee in the form of a cashiers check or money order in the amount of $100.00 made payable to National Park Service. Credit card payments may be accepted at some parks. Application and administrative charges are
Note that this is an application only, and does not serve as permission to conduct any use of the park. If your request is approved, a permit containing applicable terms and conditions will be sent to the person designated on the application. The permit must be signed by the responsible person and returned to the park prior to the event for final approval by the Park Superintendent.
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NOTICES
Privacy Act Statement: The Privacy Act of 1974 (5 U.S.C. 552a) provides that you be furnished with the following information in connection with information required by this application. This information is being collected to allow the park manager to make a value judgment on whether or not to allow the requested use. Applicants are required to provide their social security or taxpayer identification number or activities subject to collection of fees by the National Park Service (31 U.S.C. 7701) Information from the application may be transferred to appropriate Federal, State, local agencies, when relevant to civil, criminal or regulatory investigations or prosecutions.
Paperwork Reduction Act Statement): This information is being collected subject to the Paperwork Reduction Act (44 U.S.C. 3501) to allow the park manager to make a value judgment on whether or not to allow the requested use. All applicable parts of the form must be completed. A Federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information 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 National Park Service, Special Park Uses Program Manager, 1849 C Street NW (2460), Washington, D.C. 20240
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