(NPS Form 10-930) (OMB No. 1024-0026)
(NEW11/09) (Expires 09/30/2010)
National Park Service
De SotoNational Memorial
Application for Special Use 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.)
Applicant Name: Social Security # _______________________
Organization Name (if applicable): Tax ID #__________________________
Street/Address:__________________________________________________________________________________ City/State/Zip Code:
Description of Proposed Activities:
Date (s): Set-up will begin at:
Event will begin at: Removal will be completed by:
Maximum Number of Participants (Please provide best estimate)
Maximum Number of Vehicles (attach parking plan)
Support Equipment (generators, amplification, etc.)
Support Personnel (contractors, etc.)
Individual (if other than applicant) in charge of event on site:
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) Y N
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.
Note that this is an application only, and does not serve as permission to conduct a special event or any other use of a National Park. If your request is approved, a permit containing applicable conditions and regulations will be sent to the person designated on the application. The permit must be signed and returned to the park prior to the event.
Return this application to: Permit Coordinator
National Park Service
De Soto National Memorial
PO Box 15390
Phone (941) 792-0458 ext 106 Fax (941) 792-5094
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.
CONDITIONS OF THIS PERMIT
1. The permittee shall exercise this privilege subject to the supervision of the Superintendent, and shall comply with all applicable laws and regulations of the area.
2. Damages - The permittee shall pay the United Statesfor any damage resulting from this use which would not reasonably be inherent in the use which the permittee is authorized to make of the land described in this permit.
3. Benefit - Neither Members of, nor Delegates to Congress, or Resident Commissioners shall be admitted to any share or part of this permit or derive, either directly or indirectly, any pecuniary benefits to arise there from: Provided, however, that nothing herein contained shall be construed to extend to any incorporated company, if the permit be for the benefit of such corporation.
4. Assignment - This permit may not be transferred or assigned without the consent of the Superintendent, in writing.
5. Revocation - This permit may be terminated upon breach of any of the conditions herein or at the discretion of the Superintendent.
6. The permittee is prohibited from giving false information; to do so will be considered a breach of conditions and be grounds for revocation [Re: 36 CFR2.32(a)(4)].
7. Permittee will comply with applicable public health and sanitation standards and codes.
8. Advertisements must not imply endorsement by the Service or the U.S.Department of the Interior. Whenever a film company wishes to use the NPS Arrowhead symbol, the permission of the Director is required. The Director may authorize the use of the Arrowhead for uses that will contribute to purposes of education and conservation as they relate to the program of the National Park Service. All other uses are prohibited.