Form GSA Form 3453 GSA Form 3453 Application/Permit For Use Of Space In Public Buildings

APPLICATION/PERMIT FOR USE OF SPACE
IN PUBLIC BUILDINGS AND GROUNDS

OMB Number: 3090-0044
Expires: 10/31/2012

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to the Office of Facilities Management and Services Programs (PM), GSA Public Buildings
Service, Washington, DC 20405.
INSTRUCTIONS: This form allows the Applicant to request the use of federally owned property in accordance with 40 U.S.C. § 581(h) and Federal Management Regulation 41
C.F.R. part 102-74, subpart D. The Applicant must accurately describe the proposed use and, if approved, the form will serve as the permit for that use. Please submit the form
to the federal property manager responsible for the property.
Note: If the proposed use is a farmers market, the Applicant must confer with the Federal property manager and regional counsel to determine whether a permit (GSA 3453); a
license (GSA 1582); or an outlease is the appropriate vehicle for the specific circumstances of each market.

PART I - APPLICATION
APPLICANT
FIRST NAME

MIDDLE

MAILING ADDRESS

LAST NAME
STREET

TELEPHONE NUMBER

EXTENSION

E-MAIL ADDRESS
CITY

STATE

ZIP CODE

STATE

ZIP CODE

STATE

ZIP CODE

SPONSOR, PROMOTER OR CONDUCTOR OF PROPOSED ACTIVITY
NAME OF PERSON OR ORGANIZATION

MAILING ADDRESS
STREET

TELEPHONE NUMBER
AREA CODE

PHONE

EXTENSION

CITY

SUPERVISION OF/AND RESPONSIBILITY FOR THE PROPOSED ACTIVITY
NAME OF PERSON

MAILING ADDRESS
STREET
TELEPHONE NUMBER

AREA CODE

PHONE

EXTENSION

CITY

DESCRIPTION OF PROPOSED ACTIVITY

PROPOSED BUILDING

PROPOSED AREA
APPROXIMATE NUMBER OF PERSONS TO
BE ENGAGED IN THIS ACTIVITY (If known)

PROPOSED DATES AND HOURS DURING WHICH THE ACTIVITY IS TO BE CARRIED OUT
FROM

TO

HOURS

IMPORTANT: If applicant purports to represent an organization, a letter or other documentation that the applicant has authority to
represent that organization is required to be submitted with this form.
APPLICANTS PROPOSING TO ENGAGE IN THE SOLICITATION OF FUNDS MUST CHECK ONE OF THE FOLLOWING STATEMENTS:

I HEREBY 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 26 U.S.C. 501(c)(3), (c)(4), or (c)(5); or
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 determination of such status.
CERTIFICATION: I CERTIFY that the above information is true and correct.
SIGNATURE OF APPLICANT

DATE SIGNED

PART II - PERMIT (TO BE COMPLETED BY GSA ONLY)
DESIGNATED BUILDING AND AREA, ACTUAL DATES AND HOURS, FOR WHICH ACTIVITY APPROVED
BUILDING

AREA

FROM

TO

HOURS

GSA APPROVING OFFICIAL
SIGNATURE

GENERAL SERVICES ADMINISTRATION

NAME OF OFFICIAL

DATE SIGNED

GSA 3453 (REV. 9/2012)

PART III - CONDITIONS
By submitting this form, Applicant agrees to the following terms and conditions:
Applicant will conduct the proposed activity strictly in accordance with the description of the activity in this permit.
Applicant must submit, as part of this permit, a copy, sample or accurate description of any materials proposed for distribution at
the event.
Unless otherwise agreed to, in writing, by GSA and incorporated into this permit, the Applicant assumes all responsibility for, and
costs and expenses associated with, clean-up of the grounds, providing trash containers and disposal of trash, as well as any
additional security, electrical and water or related services needed to support the activity. Portable restroom facilities may be
authorized, at Applicant's sole cost and expense, if Applicant arranges for the removal before the beginning of the next business
day.
GSA will neither store nor assume any responsibility for any materials that are used for an event.
By signing the permit application and without the need for further documentation, Applicant hereby indemnifies and saves
harmless the United States, its agents and employees, in both their personal and official capacities, against any and all loss,
damage, claim, or liability whatsoever, due to personal injury or death, or damage to property of the Federal Government or
others, directly or indirectly, due to the exercise by Applicant of the privilege granted by this permit, or any act or omission of
Applicant, including failure to comply with the obligations of this permit.
In keeping with federal policy regarding retention of records associated with federal contracts and the like, GSA will retain a copy
of the permit for three (3) years from the date of issuance.
Special terms and conditions related to this permit are listed below (and continued on the following page(s), if necessary):

SIGNATURE OF APPLICANT

DATE SIGNED

If the request to use federal space is denied or an issued permit is cancelled, the Applicant may appeal within 5 calendar days of the
notification of disapproval or cancellation to the GSA Regional Administrator or his/her designee. For more information about how to
request the use of Federal property under 40 U.S.C. § 581(h) and Federal Management Regulation 41 C.F.R. part 102-74, subpart D,
please contact GSA's Office of Facilities Management and Services Programs (PM), 1800 F Street, NW, Washington, DC 20405 or visit
www.gsa.gov

GSA 3453 (REV. 9/2012) BACK