NPS Form 10-930
December 1999		 OMB No. 1024-0026

United States Department of the Interior
National Park Service
Sagamore Hill National Historic Site
Application for Special Park Uses Permit

Please supply the information requested below. Use additional sheets if necessary. Allow at least four (4) business days for processing. A non-refundable processing fee may be required to accompany this application unless the requested use is an exercise of a First Amendment right. You will be notified of the disposition of the application and the necessary steps to secure your final permit. (Note: there may be additional fees charged, and you may be required to provide proof of liability insurance.)

1.    Applicant Name:

2.    Social Security #

3.    Organization Name (if applicable):

4.    Tax ID #

5.    Street/Address:

6.    City/State/Zip Code:

7.    Telephone number:

8.    Description of Proposed Activities:

 

 

9.    Requested Location:

 

10.    Date (s): Set-up will begin at:

 

11.    Event will begin at:

 

12.    Removal will be completed by:

 

13.    Maximum Number of Participants (Please provide best estimate)

 

14.    Maximum Number of Vehicles (attach parking plan)

 

15.    Support Equipment (generators, amplification, etc.)

 

16.    Support Personnel (contractors, etc.)

 

17.    Individual (if other than applicant) in charge of event on site:

 

Y N Is this an exercise of First Amendment Rights?
Y N Are you familiar with/ have you visited the requested area?
Y N Do you plan to advertise or issue a press release?
Y N Will you distribute printed material?
Y N Is there any reason to believe there will be attempts to disrupt, protest or prevent your event?(if yes explain on separate sheet)

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.

 
Signature Date

 Return this application to
Special Park Uses Coordinator
National Park Service
20 Sagamore Hill Road
Oyster Bay NY 11771-1807		 Phone (516) 922-4788
Fax (516) 922-4792

Paperwork Reduction Act Statement: This information is being collected to allow the park manager to make a valued judgement on whether or not to allow the requested use. All the applicable parts of the form must be completed.

Estimated Burden Statement: Public reporting burden for this form is estimated to average 30 minutes per response including the time it takes to read, review instructions and complete the form. Direct comments regarding this burden estimate or any aspects of this form to the National Park Service Program Manager, Special Park Uses, Ranger Activities Division, 1849 C Street, NW., Washington, D.C. 20240 and to the Information Collection Clearance Officer, Washington Administrative Program Center, 1849 C Street, NW., Washington, D.C. 20240. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.

Sagamore Hill Application Instructions: If responses exceed space allowed on the form, attachments - hand written or typed are greatly appreciated. Each question (questions can be combined on one page) should have the number and headings for that question. Example:

8.    Description of Proposed Activities
    The event is…

A non-refundable $50 processing fee payable to the National Park Service may be required to accompany this application unless the requested use is an exercise of a First Amendment right. The fee is payable by check, money order or credit card. If National Park Service facilities or staff are required to administer this special use activity, estimated costs will be provided to the applicant and  payable in advance.

 

___Mastercard ___Visa___ Discover ________________________________________________Exp Date:_______________

Authorizing Signature ___________________________________________________________________________________