10-933 Application for Special Use Permit - Vehicle/Watercraft

NPS Form 10-933 (Rev. 08/2021) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

APPLICATION FOR SPECIAL USE PERMIT Vehicle / Watercraft Use [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 cost recovery charges and proof of liability insurance naming the United States of America an additional insured.

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

Type of Permit

Off-road vehicle

Commercial vehicle access

Snowmobile

Vehicle parking

Watercraft

Applicant Information

Applicant Name
Telephone
Cell
Company
Address (Street/PO box, city, state, zip code)
Year-round Resident? (Yes or no)
Social Security Number or Tax ID #
Driver’s License Number (DLN)
DLN Issuing State
DLN Expiration Date
Email Address
Emergency Contact Name
Emergency Contact Phone #

Additional Drivers

Limit of ____ drivers, attach additional pages if necessary

Name	Driver’s License Number	Issuing State	Expiration Date

Type of Vehicle

Passenger car

Van / light truck

Utility van / truck

RV / camper / trailer

Bus

Snowmobile

ATV / UTV

Semi / 18-wheeler

Oversized load

Watercraft

Vehicle Information

Skip fields irrelevant to your vehicle

Vehicle ID Number (VIN)
License Plate / Registration #
Issuing State
Expiration Date
Year
Make
Model
Color
Weight
Length
Height
Axels
Watercraft Motor(s)	Inboard Outboard
Number of Watercraft Motors
Watercraft Motor Horsepower (Each)

4-wheel drive vehicle? Yes No

Is your vehicle required to undergo state inspections?

Yes No

If yes, what is the expiration date?

Vehicle Insurance

Company Name
Policy Number (attach copy of valid insurance card)

Permit Request Details

Permit Duration	Seven day Annual Day use Overnight Other (please specify):
Start Date
Requested Use Area or Route

Business Information (if applicable)

Business Name
Select Type of Business	Contractor Sanitation / refuse Plumbing Electrical HVAC Delivery Transportation (bus, taxi, etc.) Public Utility Municipal Other (please specify):

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
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 also may 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 assist Park staff to 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-1.

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:

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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)