NPS Form 10-930s (Rev. 07/2016) OMB Control No. 1024-0026
National Park Service Expiration Date 01/31/2020
Page 2 of 2
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
credit card payment, cashier’s check or money order made payable to the National Park Service to Concessions 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electronic fund transfer, funds may be withdrawn from your account as soon as the same day we receive your payment, and you will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 notices of system of records.
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 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, 12201 Sunrise Valley Drive, Mail Stop 242, Reston, VA 20192.
Please do not send your form to this address.
