Filming / Photography Long 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 or send your request for the 10-932 Application for CFSP Long Form to:

Attn: Amber Siewin
Indiana Dunes National Lakeshore

1100 N. Mineral Springs Road

Porter, IN 46304

Application for Special Use Permit

Commercial Filming / Still Photography

(Long Form)

NPS Form 10-932 (Rev. 06/2016)

OMB Control No. 1024-0026

National Park Service

Expiration Date XX/XX/2019

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.

* Enter either a social security number OR a tax ID number; we do not require both.

Applicant Name:

Social Security Number*:

Street Address:

City:

State:

Zip Code:

Country :

Cell Phone Number:

Telephone Number:

Fax Number:

Email Address:

Company/Organization Name:

Tax Identification Number*:

Street Address:

City:

State:

Zip Code:

Country :

Contact Name:

Cell Phone Number:

Telephone Number:

Fax Number:

Email Address:

PROJECT INFORMATION

Project Name:

Telephone Number:

Cell Phone Number:

Location Manager:

Email Address:

Type of Project:

[ ] Video/Motion Picture/Movie

[ ] Still Photography

Detailed Description of Onsite Activities (attach additional pages, if necessary)

LOCATION SCHEDULE

* number in this column should include all individuals present at the location

Date | Location | Start Time - End time | Interior/Exterior | Activity: Set-Up/Film/ | Non-Filming/Breakdown | Number of Cast/Crew*

TALENT

Talent comprises anyone in front of the camera and includes, but is not limited to, actors, hosts, correspondents, presenters, park visitors, cooperators, volunteers, National Park Service and concessioner staff, etc.

Do you intend to utilize talent? [ ] Yes [ ] No If “Yes”, provide a full description below of who they are and how they will be utilized. (attach additional pages, if necessary)

EQUIPMENT

Description of equipment, backdrops, sets, props (attach additional pages, if necessary). Please note if any of the following will be included: weapons, animals, minors, nudity.

ELECTRICAL REQUIREMENTS

Description of electrical requirements (attach additional pages, if necessary).

Generators? If “Yes”, provide quantity and size. [ ] Yes [ ] No

Quantity:

Size:

LIGHTING REQUIREMENTS

Lighting? [ ] Yes [ ] No (If “Yes”, explain below)

Reflectors Only? [ ] Yes [ ] No

Description of lighting requirements (attach additional pages, if necessary).

ROAD USE

Will you require the use of roads? [ ] Yes [ ] No If “Yes”, please explain:

Do you require road closures? [ ] Yes [ ] No

If “Yes”, please provide the following information (attach additional pages, if necessary)

Starting Date | Ending Date | Starting Time | Ending Time | Location

Types of Shots:

[ ] Driving

[ ] Drive-by

[ ] Towing

[ ] Wet down road

[ ] Drive-ups and away

[ ] Other (explain):

CAMERA EQUIPMENT

Camera/Equipment Location:

(Check all that apply)

[ ] Road shoulder

[ ] Road median

[ ] Other (explain):

Types of Equipment:

(Check all that apply)

[ ] Hand

[ ] Tripod

[ ] Dolly

[ ] Dolly w/track footage

[ ] Arm footage

[ ] Crane or jib arm

[ ] Portable crane

[ ] Car mount

[ ] Camera car, shot maker, or process trailer

OPERATIONAL INFORMATION

NUMBER OF VEHICLES:

NOTE: Large or oversized vehicles may not be able to be accommodated or additional steps may need to be taken to ensure that no damage to park resource occurs.

Cars, SUVs, or light pick-up trucks

Vehicles greater than a 10,000 lbs. (class 3 or higher)

BASE CAMP LOCATION (attach diagrams)

SPECIAL ACTIVITIES (attach additional pages, if necessary)

INVOLVEMENT OF MINORS

Will children be involved? [ ] Yes [ ] No If “Yes”, provide number of children and age range.

Quantity:

Age Range:

LIVESTOCK OR TRAINED ANIMALS

Will livestock or trained animals be used? [ ] Yes [ ] No If “Yes”, provide the following:

Type | Quantity | Manner of Transportation | Staging/Coral Requirements

AIRCRAFT

NOTE: All aircraft use over park lands should be listed. Landings must be specifically requested and approved as a condition of your permit.

Will aircraft be used? [ ] Yes [ ] No If “Yes”, explain below (attach additional pages, if necessary)

SPECIAL EFFECTS (including weapons, pyrotechnics, etc.) (attach additional pages, if necessary)

Effects Technician’s Name:

Contact Phone Number:

Email Address:

License # (if applicable) Permit # (if applicable)

STUNTS

Will stunts be used? [ ] Yes [ ] No If “Yes”, explain below (attach additional pages, if necessary)

Stunt Coordinator:

Contact Phone Number:

Email Address:

OTHER OR HAZARDOUS ACTIVITIES

Any other unusual or hazardous activities? [ ] Yes [ ] No If “Yes”, explain below (attach additional pages, if necessary)

OPERATIONAL INFORMATION

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

When answering “Yes” to any of the following questions, provide additional information using additional pages, as necessary

Do you have, or are you applying for, a permit with another Federal, State or local agency for this activity? [ ] Yes [ ] No

Have you had previous permits from the National Park Service? [ ] Yes [ ] No

Have you ever been denied a permit or had a permit revoked by a Federal agency? [ ] Yes [ ] No

Have you forfeited a bond or other security for filming on Federal lands? [ ] Yes [ ] No

Are there any pending Federal investigations against you which involve a commercial filming activity? [ ] Yes [ ] No

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

Do you anticipate any security concerns? If yes, explain (attach additional sheet). [ ] Yes [ ] No

NOTE: You are encouraged to attach additional pages with information useful in evaluating your permit request including: story boards or scripts, set construction, parking plan, security plans, sanitary facilities, crowd control, emergency medical plan, off-road activity, trail use, use of any building and site clean-up.

PROJECT ADMINISTRATION

Are you applying for this permit on behalf of another person or company? [ ] Yes [ ] No

If “Yes”, provide a full description (including contact information) of all other individuals/companies involved with this project (attach additional pages, as necessary)

CONTACTS

Person on Location Responsible for Adherence to All Terms and Conditions of Permit:

Name:

Title:

Telephone Number:

Cell Phone Number:

Email Address:

Person on Location Responsible for Coordinating Activities with the NPS:

Name:

Title:

Telephone Number:

Cell Phone Number:

Email Address:

Company Point-of-contact for Follow-up Information and Billing:

Name:

Title:

Telephone Number:

Cell Phone Number:

Email Address:

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. All estimates are reliable to the best of my knowledge and I have the full authority to represent the applicant/production company and the project described above.

Printed Name:

Title:

Company Name:

Signature:

Date:

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 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. OMB has approved this collection of information and assigned Control No. 1024-0026.

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

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