Form NRC Form 590 NRC Form 590 NRC Form 590, Application/Permit for Use of the Two Whit

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0181

NRC FORM 590
(M-YYYY)

APPLICATION/PERMIT FOR USE OF THE
TWO WHITE FLINT NORTH (TWFN) AUDITORIUM

EXPIRES: MM/DD/YYYY

Estimated burden per response to comply with this voluntary information collection request: 15
minutes. This information is requested by NRC to determine the acceptability of the user and
the scheduling and services needed. Send comments regarding burden estimate to the
Records and FOIA/Privacy Services Branch (T-5 F52), U.S. Nuclear Regulatory Commission,
Washington, DC 20555-0001, or by internet e-mail to infocollects@nrc.gov, and to the Desk
Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0181), Office of
Management and Budget, Washington, DC 20503. If a means used to impose an information
collection does not display a currently valid OMB control number, the NRC may not conduct or
sponsor, and a person is not required to respond to, the information collection.

INSTRUCTIONS: Please submit with this application a copy, sample, or description of any material or item(s) proposed for distribution or display.
Complete the check list of service needs for public-use space on the reverse of this form. Failure to complete this form will result in denial of a permit.
IMPORTANT: If the applicant proposes to represent an organization, a letter or other documentation, on letterhead from that organization, that the
applicant has authority to represent that organization must be submitted with this form.
1. PROPOSED
DATE(S)

FROM (MM/DD/YYYY)

HOUR

A.M.

TO (MM/DD/YYYY)

HOUR

A.M.

P.M.

P.M.

2. NAME OF APPLICANT AND TITLE (First, Middle Initial, Last)

BUSINESS ADDRESS (Street, Suite/Apt. No., City, State, ZIP Code)

ESTIMATED NUMBER OF PARTICIPANTS

BUSINESS TELEPHONE NUMBER (Include Area Code)

BUSINESS EMAIL ADDRESS

BUSINESS FACSIMILE NUMBER (Include Area Code)

3. NAME OF PERSON(S) AND TITLE, ORGANIZATION(S) SPONSORING, PROMOTING, OR CONDUCTING THE PROPOSED ACTIVITY

BUSINESS TELEPHONE NUMBER (Include Area Code)

BUSINESS ADDRESS (Street, Suite/Apt. No., City, State, ZIP Code)

4. NAME OF PERSON(S) AND TITLE OF WHO WILL SUPERVISE/BE RESPONSIBLE FOR THE PROPOSED ACTIVITY

BUSINESS TELEPHONE NUMBER (Include Area Code)

BUSINESS ADDRESS (Street, Suite/Apt. No., City, State, ZIP Code)

5. DESCRIPTION OF PROPOSED ACTIVITY

6. CERTIFICATION
AN APPLICANT PROPOSING TO ENGAGE IN THE SOLICITATION OF FUNDS MUST CHECK ONE OF THE FOLLOWING STATEMENTS:
I CERTIFY THAT:

I represent and will be soliciting funds for the sole benefit of a religion or religious group.
My organization has received an official Internal Revenue Service (IRS) ruling or letter of determination stating that the
organization or its parent organization qualifies for tax-exempt status under 2 6 U.S.C. 501(c)(3),(c)(4), or (c)(5).
My organization has applied to the IRS for a determination of tax-exempt status under 26 U.S.C. 501(c)(3),(c)(4), or (c)(5)
and that the IRS has not yet issued a final administrative ruling or determinat ion of such status.
I certify that I am authorized to sign this application on behalf of the named organization. I have read and fully comprehend all
fees, rules, and regulations contained in the policies and procedures associate d with the use of the Two White Flint North
Auditorium. I fully accept liability for any damages that may occur during the scheduled use or any additional charges that may
result from the designated use of the auditorium.
SIGNATURE - APPLICANT

NRC FORM 590 (M-YYYY)

DATE

PRINTED ON RECYCLED PAPER

CHECK LIST OF SERVICE NEEDS FOR PUBLIC-USE SPACE
AUDITORIUM (Check items needed)

CATERING KITCHEN
WILL FOOD OR DRINK BE SERVED DURING PROGRAM HOURS?

MICROPHONE
PODIUM

YES

NO

It is the user's responsibility to ensure that the kitchen is
clean and in order before leaving the premises.

DIAS CONFIGURATION

NRC USE ONLY BELOW THIS LINE

SCHEDULE OF HOURLY COSTS FOR SERVICES
All programs are after NRC normal hours of operation. The following is a sched ule of hourly costs for requested services.
FEE SCHEDULE

FEE

PER HOUR

FROM

A.M. P.M.

TO

A.M. P.M.

COST

$ 238

TOTAL

ADMINISTRATIVE REVIEW
APPROVED

DISAPPROVED

IF DISAPPROVED, REASON FOR DISAPPROVAL

REVIEWING OFFICIAL (Typed or printed name and title)

SIGNATURE

DATE

SECURITY REVIEW
APPROVED

DISAPPROVED

REVIEWING OFFICIAL (Typed or printed name and title)

SIGNATURE

DATE

PERMIT FOR USE OF THE TWO WHITE FLINT NORTH AUDITORIUM
APPROVED
BASED UPON ADMINISTRATIVE AND SECURITY REVIEWS, THIS APPLICATION IS

DISAPPROVED

REVIEWING OFFICIAL (Typed or printed name and title)

SIGNATURE

DATE