NPS Form 10-931
December 1999		 OMB No. 1024-0026

United States Department of the Interior
National Park Service
Sagamore Hill National Historic Site
Application for Photography/Filming Permit - Short Form

1.    Company Name:

2.    Address:

3.    City/State/Zip

4.    Tax ID or Soc. Security #:

5.    Email:                            

6.    Phone/Fax/Beeper:

7.    Location Manager/Agent:

8.    Phone/Fax/Beeper:

9.    Project/Client Name:

 

10.    Type of Project:

 

11.    Producer:

 

12.    Photographer/Director:

 

13.    Set Contact:

 

14.    Local Contact:

 

15.    Local Phone:

 

16.    Start Date:

 

17.    End Date:

Summary of Activities and Scene(s):

 

 

SCHEDULE BY LOCATION(S) (Includes filming, parking and base camp):
Date Location Start Time End Time Type of Activity

(e.g., film, prep, or strike)

Description of Equipment/Props:

 

Max. Number of Cast and Crew:

 

Number/Type(s) of Vehicles:

 

Use of Roads and/or Trails? (Y/N): Describe:

I hereby state that the above information given is complete and correct and that no false or misleading information or false statements have been given. All estimates are reliable to the best of my knowledge and I have the full authority to represent the applicant entity and the project described above.
Signature Print Name Date:
Title: Company Name

Information provided will be used to determine whether a permit will be issued. Completed application must be accompanied by an application fee in the form of a check or money order in the amount of $50.00 made payable to National Park Service. Application and administrative charges are non-refundable.

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.

Payment of the $50 application fee is payable by check, money order or credit card.

___Mastercard ___Visa___ Discover ________________________________________________

Exp Date:_______________

Authorizing Signature ___________________________________________________________________________________

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