Complex Activity Application, Special Use Permit: Long Form

PLEASE NOTE: This form is available in printed paper format at the Indiana Dunes National lakeshore Headquarters (address is listed below). For more information, contact Amber Siewin at (219) 395-1859, for more information or send your request for the 10-930 Application for SUP Long 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 $200.00 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:
Social Security Number*:
Tax Identification Number*
* Enter either a Social Security Number OR a tax ID number; we do not require both.
Street Address:
Country:
City:
State:
Zip Code:
Country:
Cell Phone Number:
Fax Number:
Telephone Number:
Email Address:

Company/Organization Name:
Street Address:
City:
State:
Zip Code:
Country:
Contact Name:
Telephone Number:
Fax Number:
Email Address:
Description of Proposed Activity (attach diagram and/or additional pages, if necessary):
Requested Location:

Set-Up Begins:

1. Date

Time [ ] AM [ ] PM

2. Date

Time [ ] AM [ ] PM

3. Date

Time [ ] AM [ ] PM

Activity Begins:
1. Date

Time [ ] AM [ ] PM

2. Date

Time [ ] AM [ ] PM

3. Date

Time [ ] AM [ ] PM
Activity Ends:
1. Date

Time [ ] AM [ ] PM

2. Date

Time [ ] AM [ ] PM

3. Date

Time [ ] AM [ ] PM

Removal Completed:
1. Date

Time [ ] AM [ ] PM

2. Date

Time [ ] AM [ ] PM

3. Date

Time [ ] AM [ ] PM
Maximum Number of Participants (Best Estimate):
Maximum Number of Vehicles (attach parking plan):
Cars:
Vans/Light Trucks:
Utility Vans/Trucks:
Buses/Oversized Vehicles:
Support equipment (list all equipment; attach additional pages if necessary):
List support personnel including addresses and telephones; attach additional pages if necessary

Name:

Address:

Cell Phone Number:

Name:

Address:

Cell Phone Number:

Name:

Address:

Cell Phone Number:


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

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

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

Have you obtained a permit from the National Park Service in the past?

(If yes, provide a list of permit dates and locations on a separate page.) [ ] Yes [ ] No

Do you plan to advertise or issue a press release before the event? [ ] Yes [ ] No

Will you distribute printed material? [ ] Yes [ ] No

Is there any reason to believe there will be attempts to disrupt, protest or prevent your event?

(If yes, please explain on a separate page.) [ ] Yes [ ] No

Do you intend to solicit donations or offer items for sale? (These activities may require an additional permit.) [ ] Yes [ ] No

You are encouraged to attach additional pages with information useful in evaluating your permit request including: staging, sound systems, parking plan, security plans, sanitary facilities, crowd control, emergency medical plan, use of any building, site clean-up, etc.
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 statements have been given.
Printed Name:
Title:
Signature:
Date:

NOTICES
IMPORTANT NOTICE TO APPLICANT
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 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
General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals completing this application.
Authority: The authority to collect information on the attached form is derived from Title 31, United States Code, Section 7701.
Purposes and Uses: The information being collected to allow the park manager to make a value judgment on whether or not to allow the requested use. Information from the application may be transferred to appropriate Federal, State, and local agencies, when relevant to civil, criminal or regulatory investigations or prosecutions.
Effects of Nondisclosure: It is in your best interest to answer all of the questions. 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 not granting you a Special Use Permit
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 (31 U.S.C. 7701). Although disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or delay the processing of your application. The authority for soliciting and verifying your SSN is Executive Order 9397. The information gathered through the use of the SSN will be used only as necessary for processing this application and 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 30 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 $
Credit Card Number:
Expiration Date Security Code
Type of Credit Card:

[ ] American Express

[ ] Discover

[ ] Mastercard

[ ] Visa

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:

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

NPS Form 10-930 (Rev. 06/2016)
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