Form 10-741a Application for a Scientific Research and Collecting Per

A PPLICATION FOR A SCIENTIFIC

OMB # 1024-0236

Exp. Date 11/30/2010

Form No. 10-741a

RESEARCH AND COLLECTING PERMIT

United States Department of the Interior

National Park Service

If you are not using the automated system to prepare this application,

please fill out this form and return it to the appropriate park.

All or some of the information you provide may become available to the public.

Name of the National Park System area you are applying to:
Select one of the following: [ ] New application [ ] Renewal of a previously issued permit [ ] Modification of a previously issued permit			Please enter numbers for permit renewal or modification requests: Previously assigned NPS study number: Previously assigned NPS permit number:
Contact information for the current principal investigator
[Dr., Mr., Mrs., Ms.] First name: Last name:					Office phone #:
Mailing address					Alternative phone #:
					Office FAX #:
Name of the current institution represented					Office email address of principal investigator:
Additional investigators or key field assistants (first name, last name, office phone, office email)
Scientific Study Information
Project title (maximum 300 characters)
Purpose of the study (maximum 4000 characters)
Summary of proposed field methods and activities (extract from the study proposal where appropriate - maximum 4000 characters)
Study Schedule Initial starting date of the study: Estimated date the entire study may end:				Field Schedule Date to begin study within the park this application year: Date to end study within the park this application year: Will field study need to continue within the park next year (Yes/No):
Activity Type (select one): Research ____ Inventory ____ Monitoring ____ Other ____
Do you anticipate receiving funding assistance from the U.S. Federal Government for this study? (Yes or No) If “Yes,” specify the agency(s):
Where will data, maps, photos, etc. (not specimens) reside upon completion of this study?
Location(s) where you propose activities will take place within this National Park System area:
Your proposed method of access (vehicles, aircraft, boat, snowmobile, foot, etc.):
Handling or Collection of Specimens Would you like to handle or collect specimens? (Yes or No) If you respond “Yes,” please complete this entire section of the application (otherwise you may skip the remainder of this section). Note that all specimens collected and material originating from such specimens remain Federal property.
Scientific description of specimens to be handled or collected (include taxonomic group or name, or type of material; sample size, quantity, frequency, and location): Proposed disposition of specimens identified for handling or collection and material originating from such specimens (mark all that apply): [ ] Temporarily captured or handled (may include marking) and then released undamaged in place [ ] Temporarily retained, then destroyed through analysis or discarded after analysis (If your analysis later determines that temporarily retained specimens or material originating from such specimens in fact warrant permanent retention, contact the park research coordinator for further instructions) If you propose that specimens and/or material originating from such specimens be retained permanently, they will become part of National Park Service collections. You may request that such specimens and/or material originating from such specimens be loaned to one or more non-NPS institutions for management. If you do make this request, you accept responsibility for obtaining and submitting to NPS the signature of the official at each proposed repository using the form attached as Appendix A. [ ] Permanently retained in National Park Service collection, maintained in NPS repository [ ] Permanently retained in National Park Service collection, maintained in one or more non-NPS repositories identified in attached Appendix A (complete and submit an Appendix A for each proposed repository)
Certification I certify that this application is accurate and complete. I understand a formal study (research) proposal for new or modified studies must be provided to NPS before this application can be considered. I authorize the National Park Service to seek peer reviews of my proposal. Signature of principal investigator: __________________________________ Date: _________________________
For National Park Service use only	Date received	Assigned study number				Assigned permit number

Paperwork Reduction Act Statement: 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 valid OMB control number. Public reporting for this collection of information form is estimated to average 1.38 hours per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the forms. Direct comments regarding this burden estimate or any aspect of this form to Dr. John G. Dennis, Natural Resources (3130 MIB), National Park Service, 1849 C Street, N.W., Washington, DC 20240.

Privacy Act Notice: Scientific research, education and collecting activities within units of the National Park System that may impact parks invoke a permitting and reporting requirement per regulations at 36 CFR 1.6 (Permits), 36 CFR 2.1 (Preservation of Natural, Cultural and Archeological Resources), and 36 CFR 2.5 (Research Specimens). The National Park Service collects information about permit applicants and permittees to administer and document research, collecting, and reporting activities within parks. The information disclosed on this form is required and may result in denial of permit applications if not provided.

Appendix A: Proposed Repository for Collected Specimens

A principal investigator has requested permission to collect specimens for permanent retention in whole or in part and has requested that the specimens and/or material originating from such specimens be loaned by the U.S. National Park Service (NPS) to a repository that is not administered by the NPS. The principal investigator has been instructed to obtain the signature of the repository official(s) as part of the permit application. The following information should be completed and provided to the principal investigator. The principal investigator is responsible for ensuring the original signed form (or fax of the signed form) is received by the appropriate Park Research Coordinator. Each non-NPS institution proposed to receive loaned specimens or material originating from such specimens must complete this form. Note that all specimens collected and material originating from such specimens remain Federal property.

Principal Investigator:	Office phone #: Office FAX #: Office email address:
Project title (maximum 300 characters):
Scientific description of collected specimens and/or material originating from such specimens proposed to be loaned to the non-NPS institution identified below (include taxonomic group or name, or type of material; sample size, quantity, frequency, and location):

Non-NPS institution where specimens and/or material originating from such specimens identified in the box, above, are proposed to be deposited:

Organization Information

Institution: ________________________________________________________

Address: ________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Office Phone #: ______________________________________________

Office FAX #: ______________________________________________

Responsible official Email: _______________________________________________

This organization concurs with the proposal that collected specimens and/or material originating from such specimens identified above be loaned to this institution for the purposes of storage, management, and research subject to the “General Permit Conditions” and the terms of applicable National Park Service loan agreements (available from the park).

________________________________________________ ____________________

(Signature of responsible official at custodial institution) (Date)

________________________________________________ _________________________________________________

(Name of responsible official – please print) (Title of responsible official – please print)

The National Park Service may not conduct or sponsor, and a person is not required to respond to, this collection of information unless it displays a currently valid OMB control number. (ScientificResearchAppForm.doc; revised 11/2/10) Page 3 of 3