10-931 Application for Special Use Permit - Commercial Filming/

NPS Form 10-931 (Name Change) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

APPLICATION FOR SPECIAL USE PERMIT FILMING, STILL PHOTOGRAPHY, AND AUDIO RECORDING (Short Form) [PARK NAME] [Street Address] [City, State, Zip Code] [Phone Number for Park Permits POC]

Please supply the information requested below. Attach additional sheets, if necessary, to provide required information. A non-refundable application fee of [insert amount] must accompany this application. You must allow sufficient time for the park to process your request; check with the park for guidelines. You will be notified of the status of the application and the necessary steps to secure your final permit. Your permit may require the payment of location fees, cost recovery charges, and proof of liability insurance naming the United States of America an additional insured. Applications may not be submitted more than one year before the proposed activity including time required for set up.

* Enter either a Social Security Number OR a tax ID number; we do not require both.

Applicant Information	Company/Organization Information
Applicant Name:	Company/Organization Name:
Social Security Number*:	Tax Identification Number*:
Street Address:	Street Address:
City:	City:
State:	State:
Zip Code:	Zip Code:
Country:	Country:
Telephone Number:	Telephone Number:
Cell Phone Number:	Contact Name:
Fax Number:	Fax Number:
Email Address:	Email Address:

Project Information

Project Name
Location Manager
Telephone
Cell
Email Address

Type of Project

Still Photography Filming Audio Recording

Detailed Description of Onsite Activities (attach additional pages if needed)

Location Schedule

Date	Location	Start Time	End Time	Interior / Exterior	Activity (e.g., Set-up, Breakdown)	# of Cast and Crew*

* Number in this column should include all individuals present at the location

Equipment

Description of equipment, backdrops, sets, props (attach additional pages, if necessary). Please note if any of the following will be included: weapons, animals, minors, nudity.

Number of Vehicles

Type	Quantity
Cars, SUVs, or light pickup trucks
Vehicles greater than 10,000 lbs (Class 3 or higher)

Aircraft

NOTE: All aircraft use (including “drones” or Uncrewed Aircraft Systems) over park lands should be listed. Landings and take offs must be specifically requested and approved as a condition of your permit.

Will aircraft be used?	Yes, aircraft will be used (If yes, explain) No, aircraft won’t be used
Explanation of use

Activity Questions

When answering “Yes” to any of the following questions, provide additional information using additional pages, as necessary

Have you visited the requested area? Yes No

Do you have, or are you applying for, a permit with another Federal, state or local agency for this activity? Yes No

Have you obtained a permit from the National Park Service in the past?

(If yes, provide a list of permit dates and locations on a separate page.) Yes No

Have you ever been denied a permit or had a permit revoked by a Federal agency? Yes No

Have you forfeited a bond or other security for on Federal lands? Yes No

Do you plan to advertise or issue a press release before the event? Yes No

Is there any reason to believe there will be attempts to disrupt, protest or prevent your event? Yes No

(If yes, please explain on a separate page.)

Are there any pending Federal Investigations against you which involve a commercial filming activity Yes No

You are encouraged to attach additional pages with information useful in evaluating your permit request.

Contacts
Person on location responsible for adherence to all terms & conditions of the permit.

Name
Title
Telephone
Cell

The applicant by his or her signature certifies that all the information given is complete and correct, and that no false or misleading information or false statements have been given.

Name
Title
Company Name
Date
Signature

NOTICES

IMPORTANT NOTICE TO APPLICANT

This application does not serve as permission to conduct any special use activity in the park. The information provided will be used to evaluate whether a permit will be issued. All applicable parts of the form must be completed. Incomplete applications will not be evaluated. Send the completed application, along with the application fee in the form of a [park to select payment methods accepted: cash, cashier’s check, money order, personal check]. Checks made payable to the National Park Service and all funds must be in US Dollars to [input name/park office and address]. Fees may also be paid online by credit card or electronic funds transfer at pay.gov. The application must be signed and dated in order for the application to be considered complete.

Purposes The purposes of this application are (1) to provide a National Park Service (NPS) 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 help NPS staff 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 Title 5 U.S.C. § 552(a)(b) of the Privacy Act, records or information contained in this system may be disclosed outside the NPS as a routine use pursuant to Title 5 U.S.C. § 552(a)(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 

Effects of Nondisclosure: Failure to provide the requested information may impede your ability to obtain a permit from the NPS. 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 denying you a Special Use Permit.

If your request is approved, a permit containing applicable terms and conditions will be sent to 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.

PAPERWORK REDUCTION ACT STATEMENT

We are collecting this information subject to the Paperwork Reduction Act (Title 44 U.S.C. § 3501) to provide the Park Superintendent information needed to evaluate whether a permit will be issued for the requested use. 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. The authority to collect information on the attached form is derived from Title 31 U.S.C. § 7701. Taxpayer identifying number, Title 54 U.S.C. § 100101, Promotion and regulation; Title 54 U.S.C. § 100751, Regulations; Title 54 U.S.C. § 103104, Recovery of costs associated with special use permits; and Title 54 U.S.C § 100905 Commercial filming.

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, 13461 Sunrise Valley Drive Reston, Virginia 20192. Please do not send your application to this address.

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 application. All information collected using this form will be safeguarded in accordance with established regulations and published notices of System of Records, NPS

Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b): The collection of your SSN or TIN is necessary to allow the NPS to collect fees under Title 54 U.S.C.§ 103104 and Title 54 U.S.C. §100905. Your SSN or TIN will only be used as necessary to: (1) process this application, (2) collect any associated permit fees, and (3) collect and report any delinquent financial obligations. Failure to disclose your SSN or TIN when required may prevent or delay the processing of your application and issuing the associated permit. Use of your SSN or TIN will be carried out in accordance with established regulations and published notices of system of records, NPS-1

INTERNAL AGENCY USE ONLY

Project Number/BILL:

Date Processed:

Permit Number:

Prepared By:

Organization Name:

Page 1 of 4

RECORDS RETENTION: Unapproved (3 years).  Maintain Approved applications with related permit and associated records based on appropriate item(s) in NPS Records Schedule 1, Resources Management and Lands, (N1-79-08-1)