**2008 APPLICATION FORM FOR**

**COMMERCIAL USE AUTHORIZATION**

**U.S. DEPARTMENT OF THE INTERIOR**

![](media/image1.wmf)

**National Park Service**

**USS *Arizona* Memorial**

**Attention: David Stransky, CUA Management/Enforcement**

**1 Arizona Memorial Place**

**Honolulu, HI 96818**

**(808) 422-2771 ext. 112**

**For which year(s) is the Commercial Use Authorization (CUA) being
requested?** \_\_\_\_\_\_\_\_

**IMPORTANT**: Before completing this application, please refer to **"V.
Approved Commercial Visitor Services"** located on pages 4 of the
Instruction Guide to verify that the service you are proposing is an
approved commercial service. If the service you wish to provide is
**not** listed on the table of approved commercial visitor services,
contact us at 808-422-2771, Extension 112.

*Please type or print in ink. Answer all questions completely or mark
"N/A" if not applicable*

(1) **Applicant (Legal Business Name)
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

(2) **What is your Business Type (Please check one below):**

> **A. ⁭** Sole Proprietor
>
> **B. ⁭** Corporation: (**State: *\_\_*\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> Entity Number\_\_\_\_\_\_\_\_\_\_\_\_\_\_)**
>
> **C. ⁭** Non-Profit (Please attach a copy of your IRS Ruling or
> Determination Letter)
>
> **D. ⁭** Partnership/Association. *Print the names of each partner. If
> there are more than two partners, please attach a complete list of
> their names.*
>
> ( Name
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)
>
> ( Name
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)
>
> **E. ⁭** Other (Specify)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> **Note: If the business is a non-profit that will not be generating
> taxable income from the activity, then you are not required to obtain
> a CUA. Non-profit entities may be required to obtain a Special Use
> Permit for their activity even if they are not required to obtain a
> CUA. Please contact the park for additional information concerning
> this issue.**

(3) **Mailing Addresses:**

Address:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City, State, Zip:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Email:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Internet:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Day Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Evening Phone:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Fax:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(4) **Employer's Identification Number:
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

(5) **Provide the name(s) of the authorized agent(s) (owner, general
    mgr., responsible person) for this business.**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

(6) **(a) Are you employed with the National Park Service? ⁭Yes ⁭ No.**

> **If Yes, please complete below:**
>
> Title\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Park / Office where
> employed\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> **(b) Do you have a spouse or minor children employed with the
> National Park Service? ⁭Yes ⁭ No**
>
> **If Yes, please complete below:**
>
> Title\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Park / Office where
> employed\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(7) **Expiration date of Business License: \_\_\_\_\_\_\_\_\_\_\_
    License Number: \_\_\_\_\_\_\_\_\_\_\_\_\_**

(8) **Names of employees who will work under the authority of your
    CUA:**

+-----------------------------------+----------------------------------+
| > **Names:**                      | **Titles or Position:**          |
|                                   |                                  |
|                                   | *(e.g. Guide, Pilot, Boat        |
|                                   | Operator, Driver, etc)*          |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+

(9) **Will your business operate vehicles (car, truck, van, bus,
    taxicab, etc) within NPS boundaries\_\_\_\_? ⁭Yes ⁭ No.**

> **If \"yes\", please give a description of each vehicle. Use
> additional paper if necessary.**

+--------------------+-----------+-------+---------+-------+--------+
| **MAKE OF          | **MODEL** | **Y   | **MAX   | **    | **L    |
| VEHICLE**          |           | EAR** | \#**    | OWN** | EASE** |
|                    |           |       |         |       |        |
|                    |           |       | **PASSE |       |        |
|                    |           |       | NGERS** |       |        |
+--------------------+-----------+-------+---------+-------+--------+
|                    |           |       |         |       |        |
+--------------------+-----------+-------+---------+-------+--------+
|                    |           |       |         |       |        |
+--------------------+-----------+-------+---------+-------+--------+
|                    |           |       |         |       |        |
+--------------------+-----------+-------+---------+-------+--------+

(10) Within the **past 5 years**, have you or any individual serving as
     an officer, principal, partner or employee with this business
     entity or any previous business entity, **been convicted of or
     forfeited collateral for any violations of state, federal, or local
     law or regulation? ⁭Yes ⁭ No.**

> **If \"yes\", please give a description of each violation. Attach
> additional sheets if necessary.**

Date of Violation: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Was this a conviction? \_\_\_\_\_\_\_\_ Was Collateral forfeited?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Name of Business or
> person(s)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Place of Violation?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Court Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Provide Details?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Results) Action Taken by
Court\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(11) **Is the company (current entity) or previous business entity, or
     any owners of this business entity or previous business entity now
     under charges for any violation of state, Federal, or local law or
     regulation?**

> **⁭Yes ⁭ No.**
>
> **If \"yes\", please give a description of each violation. Attach
> additional sheets if necessary.**

Date of Violation: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Place of Violation?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Who is the Charge against?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Who made the Charge(s)?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Provide Details of charge(s)?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Current Status:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(12) \***Within the past 5 years, have any of your current or proposed
     employees been convicted of or forfeited collateral for any state,
     federal, or local law or regulation; OR are they now under charges
     for any violation of state, federal or local law or regulation?**

> **⁭Yes ⁭ No.**
>
> **If \"yes\", please give a description of each violation. Attach
> additional sheets if necessary.**

***(\*Employees identified below may be precluded from working for the
operator)***

Date of Violation: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Place of Violation:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Was this a conviction? \_\_\_\_\_\_\_\_\_\_\_\_ Was Collateral
forfeited? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Name of Employees or Proposed Employees
> Involved\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Place of Violation?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Court Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Give Details?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Current Status
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**\*Note -- CHECK SECTION VI. OF APPLICATION INSTRUCTIONS FOR MINIMUM
LIABILITY INSURANCE REQUIREMENTS.**

(13) **Signature**: False, fictitious or fraudulent statements of
     representations made in this application may be grounds for denial
     or revocation of the Commercial Use Authorization and may be
     punishable by fine or imprisonment (U.S. Code, Title 18, Section
     1001). All Information provided will be considered in reviewing
     this application. Authorized Agents must attach proof of
     authorization to sign below.

*By my signature, I hereby attest that all my statements and answers on
this form and any attachments are true, complete, and accurate to the
best of my knowledge.*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature Date

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Printed Name

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Title

**Mail, FAX, or Hand Carry to:**

**National Park Service**

**USS *Arizona* Memorial**

**Attention: David Stransky, CUA Management/Enforcement**

**1 Arizona Memorial Place**

**Honolulu, HI 96818**

**(808) 422-2771 ext. 112**

**Fax: (808) 483-8608**