![](media/image1.png){width="0.9625in" height="1.25in"}**(NPS Form
10-931) National Park Service**

**(OMB No. 1024-0026) Cedar Creek & Belle Grove National Historical
Park**

**(NEW 10/00) PO Box 700, Middletown, VA 22645**

**(Expires 3/31/2010) 540-868-9176 (phone ) / 540-869-4527 (fax)**

### Application for Commercial Filming/Still Photography Permit

> Please supply the information requested below. **Attach additional
> sheets, if necessary, to provide required information**. Allow **AT
> LEAST** four (4) business days for processing. A non-refundable
> processing charge should 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. Your permit may require the payment of
> cost recovery charges, a location fee, and proof of liability naming
> United States as also insured.

  ------------------------------------ ----------------------------------
  Applicant:                           Company:

  Social Security #:                   Tax ID #:

  Street/Address:                      Street/Address:

  City/State/Zip Code:                 City/State/Zip Code:

  Telephone #:                         Telephone #:

  Cell phone #:                        Cell phone #:

  Fax #:                               Fax #:

  Email:                               Email:
  ------------------------------------ ----------------------------------

  ------------------------------------ ----------------------------------
  Project name:                        Producer:

  Type of project:                     Photographer:

  Location manager:                    Director:

  Telephone #:                         Caterer:

  Cell phone #:                        Telephone \# - set:
  ------------------------------------ ----------------------------------

Summary of Activities and Scene(s) (attach additional pages if
necessary): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**SCHEDULE BY LOCATION(S)** (Includes filming, parking and base camp):

+-----+---------------+-------+-------+-----------------+-----------+
| D   | Location      | Start | End   | # Ty            | # Num     |
| ate |               | Time  | Time  | pe of Activity  | ber of Ca |
|     |               |       |       |                 | st & Crew |
|     |               |       |       | (e.g., film,    |           |
|     |               |       |       | prep, or        |           |
|     |               |       |       | strike)         |           |
+-----+---------------+-------+-------+-----------------+-----------+
|     |               |       |       |                 |           |
+-----+---------------+-------+-------+-----------------+-----------+
|     |               |       |       |                 |           |
+-----+---------------+-------+-------+-----------------+-----------+
|     |               |       |       |                 |           |
+-----+---------------+-------+-------+-----------------+-----------+
|     |               |       |       |                 |           |
+-----+---------------+-------+-------+-----------------+-----------+
|     |               |       |       |                 |           |
+-----+---------------+-------+-------+-----------------+-----------+

Description of Equipment/Props(attach additional pages if necessary):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

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

List of vehicles including type and license plate number (attach
additional pages if necessary):

Vehicle Make and Model License Number

  -------------------------------------------------- --------------------
                                                     

                                                     

                                                     

                                                     
  -------------------------------------------------- --------------------

Use of Roads and/or Trails? (Y/N): Describe proposed use (attach
additional pages if necessary):

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

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> Are you familiar with/ have you visited the requested area? Y N
>
> Have your obtained a permit from the National Park Service in the
> past? Y N
>
> (If yes, provide a list of permit dates and locations on a separate
> page.)
>
> Do you plan to advertise or issue a press release before the event? Y
> N

I hereby state that the above 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 entity and the
project described above.

Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Print
Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date:
\_\_\_\_\_\_\_\_\_\_\_

Title: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Company Name:
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

> \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*

Information provided will be used to determine whether a permit will be
issued. Completed application must be accompanied by an application
charge in the form of a cashiers check or money order in the amount of
\$50.00 made payable to **[National Park Service]{.underline}**.
Application and administrative charges are non-refundable. *This
completed application should be mailed to the Special Park Use
Coordinator at the Park address found on the first page of this
application.*

**Note** that this is an application only, and does not serve as
permission to conduct any use of the park. If your request is approved,
a permit containing applicable terms and conditions will be sent to the
person designated on the application. The permit must be signed by the
responsible person and returned to the park prior to the event for final
approval by the Park Superintendent.

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*The above application form is provided with the understanding that
parks will insert appropriate park names and addresses and the amount of
the application fee as desired.*

**Paperwork Reduction Act Statement:** This information is being
collected to allow the park manager to make a value judgment on whether
or not to allow the requested use. All the applicable parts of the form
must be completed. A Federal 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.

**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 National Park Service, Special Park Uses Program
Manager, 1849 C Street NW (2465), Washington, D.C. 20240