Pilot Test of Web-based Application for the National Park Service U.S. Civil Rights Network USCRN)

NPS Form 10-#### (Rev. 10/2018) OMB Control No. 1090-0011

U.S. Department of the Interior Expiration Date 10/31/2021

{NETWORK LOGO when final}

U.S. CIVIL RIGHTS NETWORK APPLICATION

GENERAL INFORMATION
Date Submitted:								Element Type (Pick One):
     								Site Facility Program
Element Name:								Street Address:
     								     
City:				State:		Zip Code:		County:		Congressional District:
     				     		     		     		     
If a site, is it listed in the National Register of Historic Places? Yes No								If YES, what is the listing name?
								     
								If NO, has the SHPO certified the site as “determined eligible”? Yes (attach SHPO letter) No
If a Facility, type:		Archive	Library		Research Center				Other (Describe):      
If a Program, type:		Public Program	Tour				Performance				Living History
		Exhibit/Art	Website				Curriculum-based Education				Youth Program
		Other (Describe):      
Has the Element received a NPS African American Civil Rights grant in the past?										Address Not for Publication?
Yes No
Is there a website?				Web Address:
Yes No				     
Is the Element open to the public? Yes No						Days and Hours of Operation/Schedule:      
Is there a visitor phone number?				Phone Number:
Yes No				     
Summary: Tell us in 200 words or less what is being nominated and how it is connected to the African American Civil Rights Movement.
     

Owner/Manager (Share Contact Information Yes No)
Name:		Phone:		Fax:		Email:
     		     		     		     
Street Address:			City		State:		Zip Code
     			     		     		     
Additional Owner/Manager (Share Contact Information Yes No)
Name:		Phone:		Fax:		Email:
     		     		     		     
Street Address:			City		State:		Zip Code
     			     		     		     
Additional Owner/Manager (Share Contact Information Yes No)
Name:		Phone:		Fax:		Email:
     		     		     		     
Street Address:			City		State:		Zip Code
     			     		     		     
Additional Owner/Manager (Share Contact Information Yes No)
Name:		Phone:		Fax:		Email:
     		     		     		     
Street Address:			City		State:		Zip Code
     			     		     		     
Additional Owner/Manager (Share Contact Information Yes No)
Name:		Phone:		Fax:		Email:
     		     		     		     
Street Address:			City		State:		Zip Code
     			     		     		     
2. Ownership of Element:	Private Non-profit (501c3) Public - Local Government Public - State Government Public - Federal Government
3. Describe the Element and the history of its association or significance to the African American Civil Rights Movement in less than 1200 words. If a Program or Facility, describe how the Element educates and/or assists the public in learning about the American Civil Rights Movement. Provide citations for sources used throughout the text if needed. Timelines are encouraged.
     
4. Additional data or comments. (Optional)
     
OPTIONAL ATTACHMENTS: Applicants may submit electronic copies only of relevant supplementary materials on a single archival quality CD [i.e. up to 3, high quality (300dpi or higher) original photographs or images; a DVD of the program or sample program transcript; 1-2 brochures or interpretive materials; scan of a historic newspaper clipping or pamphlet; a facility finding aid, catalogue or index; and/or an example of an audience feedback card or questionnaire.]

NOTICES

Privacy Act Statement

General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals completing this form.

Authority: African American Civil Rights Network Act of 2017 (PL115-104).

Purpose and Uses: The U.S. Civil Rights Network was established, in part, to facilitate sharing of information among those interested in the African American Civil Rights Movement. Putting people in contact with others who are researching related topics, historic events, or individuals or who may have technical expertise or resources to assist with projects is one of the most effective means of advancing African American Civil Rights history commemoration and preservation. Privacy laws designed to protect individual contact information (i.e., home or personal addresses, telephone numbers, fax numbers, or e-mail addresses), may prevent NPS from making these connections. If you are willing to be contacted by others working on civil rights movement activities and to receive mailings about African American civil rights movement-related events, please add a statement to your letter of consent indicating what information you are willing to share. The DOI and NPS may use the information to meet reporting requirements, to generate budget estimates and track performance, and to assist park staff with visitors’ education, fee collection, resource management and protection, recreational use planning, law enforcement and public safety personnel for such purposes as emergency contact and search and rescue efforts; to provide permit holders and participants with information about parks and their partners; and to provide reports of activities conducted under an issued permit.

Disclosure: Voluntary. However, failure to provide the requested information may impede our ability to process your application. It is in your best interest to answer all of the questions. The U.S. Criminal Code, Title 18 U.S.C. 1001, provides that knowingly falsifying or concealing a material fact is a felony that may result in fines of up to $10,000 or 5 years in prison, or both. Deliberately and materially making false or fraudulent statements on this form will be grounds for not approving your application.

Paperwork Reduction Act Statement

The authority to collect this information is the African American Civil Rights Network Act of 2017 (PL115-104). We will use this information pilot test the on-line form used to evaluate properties, facilities, and programs nominated for inclusion in the U.S. Civil Rights Network. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB control number. Your response is required to obtain or retain a benefit. OMB has approved this collection of information and assigned control number 1090-0011.

Estimated Burden Statement

Public reporting for this collection of information is estimated to average 30 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 Information Collection Officer, National Park Service, 12201 Sunrise Valley Dr. (MS-242), Reston, VA 20192.

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