![](media/image1.png){width="0.9243055555555556in" height="1.2in"}**(NPS
Form 10-932) 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 insurance naming the
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 #:

  E-mail:                               E-mail:
  ------------------------------------- ---------------------------------

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

  Location manager:                     Photographer:

  Telephone #:                          Director:

  Cell phone #:                         Insurance company:

  E-mail:                               
  ------------------------------------- ---------------------------------

**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  Infomercial  Industrial  Public Service Announcement

 Other, explain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

**Detailed description of on-site activities**

Talent comprise 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 concessionaire staff,
etc.

**Do you intend to utilize talent?**  Yes  No

If yes, provide a full description of who they are and how they will be
utilized:

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**LOCATION SCHEDULE:**

+-----+-----------------+-----+-----+---------+------------+--------+
| D   | LOCATION        | St  | End | I       | FILM       | \# of  |
| ATE |                 | art | T   | nterior | STRIKE     | cast   |
|     |                 | T   | ime | or      |            |        |
|     |                 | ime |     | E       | PREP       | &      |
|     |                 |     |     | xterior |            | crew   |
|     |                 |     |     |         |            | **\*** |
+-----+-----------------+-----+-----+---------+------------+--------+
|     |                 |     |     |         |         |        |
+-----+-----------------+-----+-----+---------+------------+--------+
|     |                 |     |     |         |         |        |
+-----+-----------------+-----+-----+---------+------------+--------+
|     |                 |     |     |         |         |        |
+-----+-----------------+-----+-----+---------+------------+--------+
|     |                 |     |     |         |         |        |
+-----+-----------------+-----+-----+---------+------------+--------+
|     |                 |     |     |         |         |        |
+-----+-----------------+-----+-----+---------+------------+--------+
|     |                 |     |     |         |         |        |
+-----+-----------------+-----+-----+---------+------------+--------+
|     |                 |     |     |         |         |        |
+-----+-----------------+-----+-----+---------+------------+--------+

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

How will individuals with access to the site be identified?
(Identification tags are recommended.)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Electrical needs, explain Generator:  No  Yes, size
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Lighting:  None  Reflectors only  Yes
(explain)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

Road Use: Date/time: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

 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:

**Vehicles:**

Personal Cars [\_]{.underline} Large Trucks [\_]{.underline} Other
Trucks Vans \_\_\_\_\_\_ Motor homes [\_\_\_\_\_\_\_\_]{.underline}

Semi-Tractor Trailers \_\_\_\_\_\_\_ Camera Car Picture Cars Dressing
Rooms \_\_\_\_\_\_\_

Other Vehicles
(explain)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**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.**

**Vehicles or to be parked on or need access to park property (attach
additional sheets if necessary):**

  -------------- -------------- -------------- ----------- ------------------
  **MAKE**       **MODEL**      **COLOR**      **STATE**   **LICENSE PLATE
                                                           \#**

                                                           

                                                           

                                                           

                                                           

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

Base Camp location (attach diagram if necessary:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**CATERING INFORMATION**

Catering Co. Name Phone Number \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

On-site Manager
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Food License
Information:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Equipment:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**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]{.underline}

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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

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).

CONTACTS:

**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 \$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.

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

*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