**Form 10-932) (OMB No. 1024-0026)**

**(NEW 10/00) (Expires 12/31/2006)**

**NATIONAL PARK SERVICE**

**JEFFERSON NATIONAL EXPANSION MEMORIAL**

**11 NORTH FOURTH STREET**

**ST. LOUIS, MISSOURI 63102**

**PHONE: 314-655-1613 FAX: 314-655-1640**

**Application for Photography/Filming Permit**

Please supply the information requested below. This information is
required to evaluate your permit request. **Attach additional sheets, if
necessary.** Allow at least four (4) business days for processing. A
non-refundable processing fee may be required to accompany this
application. There may be additional fees charged, including a location
fee, and you will be required to provide proof of liability insurance.

  ------------------------------------- ---------------------------------
  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 #:                          Insurance company:

  Cell phone #:                         
  ------------------------------------- ---------------------------------

**TYPE OF PROJECT:**

Stills, editorial Stills, advertising stills, other stock
photo/video/film

Feature Film /TV Movie TV Series/Pilot Documentary/Travelogue Commercial

Music Video Public Service Announcement Infomercial Industrial

Other, explain

Will there be sound recording Yes No Night work : No Yes, explain

**SUMMARY OF SCENE(S):**

**SHOOTING SCHEDULE BY LOCATION:**

  ------ ----------------- ------- ------ ---------- ---------------- --------
  DATE   LOCATION          Start   End    Interior   FILM PREP STRIKE \# of
                           Time    Time   or                          cast &
                                          Exterior                    crew

                                                                      

                                                                      

                                                                      

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

Set dressing or other structures proposed: No Yes, explain

ATTACH ADDITIONAL PAGES FOR INFORMATION NEEDED TO EVALUATE YOUR PERMIT
REQUEST INCLUDING: set construction, parking, sanitary facilities, crowd
control, emergency medical plan, off-road activity, trail use, or use of
any building and site clean up. Include a proposed Site Plan(s).

Electrical needs, explain **[N/A\--THERE IS NO POWER AVAILABLE FOR YOUR
USE ON PARK GROUNDS]{.underline}**

Generator: No Yes, size **[N/A\--GENERATORS MUST BE LOCATED OFF OF PARK
PROPERTY]{.underline}**

Lighting: None Reflectors only Yes (explain)

Road: **[N/A\--THERE ARE NO ROADS WITHIN PARK BOUNDARIES, ONLY
SIDEWALKS]{.underline}**

Date/time: [N/A]{.underline} Closure requested

Running shots Driving shots Drive-bys Tow shots Drive-ups & Away Wet
down road

Camera/Equipment on Road Shoulder Camera/Equipment on median Other
(explain)

OPERATIONAL INFORMATION:

Number of Personnel and Vehicles:

Total Cast & Crew Personal Cars Large Trucks Other Trucks Vans

Camera Car Picture Cars Motor homes Dressing Rooms

Other Vehicles (explain) Base Camp location:

Catering Co. Name Phone \#
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

**SPECIAL ACTIVITIES:**

Children:  None  Yes \# of Children Age Range
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Animals:  None 
Yes (explain)

Trainer Name: Phone #:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Aircraft:  No  Yes (explain)

Special Effects: (identify)

Effects Technician Name: Phone \#
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

License \# (if applicable) Permit \# (if applicable)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Stunts: (explain)

Coordinator­­­­­­­­­­­­­­­­­­­­­­­\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Phone
#\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Any other unusual or hazardous activities, explain

**Person on location responsible for company\'s adherence to all terms &
conditions of a Film Permit**:

Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Title: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Phone:
\_\_\_\_\_\_\_\_\_\_\_\_

Person on location responsible for coordinating activities with the NPS:

Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Title: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Phone:
\_\_\_\_\_\_\_\_\_\_\_\_

**Person at the company office to contact for follow up information and
billing:**

Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Title: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Phone:
\_\_\_\_\_\_\_\_\_\_\_\_\_

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/production company
and the project described above.

**Signature \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Title \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date
\_\_\_\_\_\_\_\_\_\_\_\_**

**Company Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Information provided will be used to determine whether a permit will be
issued. Completed application must be accompanied by an application fee
in the form of a cashiers check or money order in the amount of
**[\$100.00]{.underline}** made payable to **[National Park
Service]{.underline}**. Application and administrative charges are
non-refundable. Mail application and check to:

**NATIONAL PARK SERVICE**

**JEFFERSON NATIONAL EXPANSION MEMORIAL**

**11 NORTH FOURTH STREET**

**ST. LOUIS, MISSOURI 63102**

**PHONE: 314-655-1613 FAX: 314-655-1640**

**Note** that this is an application only, and does not serve as
permission to conduct a filming project or any other use of the park. If
your request is approved, a permit containing applicable conditions and
regulations will be sent to the person designated on the application.
The permit must be signed and returned to the park prior to the event.

\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*

**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 60 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 (org. code 2460), Washington, D.C.