Simple Activity Application, Special Use Permit: Short Form

PLEASE NOTE: This form is available in printed paper format at the Indiana Dunes National lakeshore Headquarters (address is listed below). Contact Amber Siewin at (219) 395-1859, for more information or send your request for the 10-930s Application for SUP Short Form to:

Attn: Amber Siewin
Indiana Dunes National Lakeshore

1100 N. Mineral Springs Road

Porter, IN 46304

Please supply the information requested below. Attach additional sheets, if necessary, to provide required information. A nonrefundable processing fee of $65.00 must accompany this application unless the requested use is an exercise of a First Amendment right. 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.


Applicant Name :

Telephone Number:

Organization:

Cell Phone Number:

Social Security Number or Tax ID number:

Fax Number:

Email Address:

Street Address:

City:

State:

Zip Code:

Country:

Proposed Activity:

Preferred Date:

Preferred Location:

Preferred Time:

Alternate Date(s)*:

Alternate Location(s)*:

Alternate Time(s)*:

*Alternatives will be considered if first choice is not available.:

Maximum Number of Participants:

Maximum Number of Vehicles:

List of Equipment:

Individual in charge of activity onsite who is authorized to make decisions related to the permitted activity:

Cell Phone Number:

Have you visited the requested area? [ ] Yes [ ] No

Is this an exercise of a First Amendment rights? [ ] Yes [ ] No

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:

RECORDS RETENTION: TEMPORARY. Destroy/delete 3 years after closure. (NPS Records Schedule, Resource Management and Lands (Item 1D) (N1-79-08-1))

NOTICES

This is an application only, and does not serve as permission to conduct any special activity in the park. The information provided will be used to determine whether a permit will be issued. Send the completed application along with the application fee in the form of a credit card payment, cashier’s check, money order or personal check made payable to the National Park Service to Amber Siewin at Indiana Dunes National Lakeshore at the park address found on the first page of this application.

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

Privacy Act Statement

Authority: 16 U.S.C. 1, National Park Service Organic Act; 16 U.S.C. 3, Rules and regulations of national parks, reservations, and monuments; timber; leases, 16 U.S.C. 3a, Recovery of costs associated with special use permits; and 16 U.S.C. 460i–6d, Commercial Filming.

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

Disclosure: Voluntary, however, failure to provide the requested information may impede individual from obtaining a permit from the National Park Service.

Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b): Your Social Security Number (SSN) is needed to identify records unique to you. Applicants are required to provide their social security or taxpayer identification number for activities subject to collection of fees and charges by the National Park Service. Failure to disclose your SSN may prevent or delay the processing of your application. The authority for soliciting your SSN is 31 U.S.C. 7701. The information gathered through the use of the SSN will be used only as necessary for processing this application and collecting and reporting any delinquent financial obligations. Use of the social security number will be carried out in accordance with established regulations and published notices of system of records.

Paperwork Reduction Act Statement

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to provide the park managers the information needed to decide whether or not to allow the requested use. All applicable parts of the form must be completed in order for your request to be considered. 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.

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, 12201 Sunrise Valley Drive, Mail Stop 242, Reston, VA 20192. Please do not send your form to this address.

Credit Card Authorization

All credit card information is protected under the Privacy Act of 1974

Applicant Name:

Cardholder Name (as it appears on card)

[ ] Same as “Applicant”

Company Name (if applicable):

Telephone Number:

Cell Phone Number:

Email Address:

Federal Taxpayer Identification or Social Security Number:

Credit Card Billing Address:

City:

State:

Zip Code:

Country:

Amount to be billed to card

Application Cost = $

Location Fee = $

Cost Recovery = $

Total = $

Type of Credit Card:

[ ] American Express

[ ] Discover

[ ] MasterCard

[ ] Visa

Credit Card Number:

Expiration Date Security Code:

I hereby authorize my card to be charged the amount indicated above in connection with the issuance of the requested Special Use Permit:

Cardholder Authorized Signature:

Date:

INTERNAL AGENCY USE ONLY

Project Number/BILL:

Date Processed:

Permit Number Prepared By:

Organization Name:

NPS Form 10-930s

(Rev. 07/2016)

OMB Control No. 1024-0026

National Park Service

Expiration Date XX/XX/2019

Last updated: January 5, 2018

Contact the Park

Mailing Address:

1100 North Mineral Springs Road
Porter, IN 46304

Phone:

(219) 395-1882
Indiana Dunes Visitor Center phone number.

Contact Us