NPS Form 10-932 (Rev. 08/2021) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

APPLICATION FOR SPECIAL USE PERMIT 

Still Photography 

(Long Form)

Theodore Roosevelt Birthplace National Historic Site

Attention: Business Management Program 

26 Wall Street, New York, NY 10005 

masi_special_park_use@nps.gov

Page 1 of 4

RECORDS RETENTION: Unapproved (3 years). Maintain Approved applications with related permit and associated records based on appropriate item(s) in NPS

Records Schedule 1, Resources Management and Lands, (N1-79-08-1)

Please supply the information requested below. Attach additional sheets, if necessary, to provide required information. A 

nonrefundable processing fee of $50.00 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 Information Company/Organization Information

Applicant Name: Company/Organization Name:

Social Security Number*: Tax Identification Number*:

Street Address: Street Address:

City: City:

State: State:

Zip Code: Zip Code:

Country: Country:

Telephone Number: Telephone Number:

Cell Phone Number: Contact Name:

Fax Number: Fax Number:

Email Address: Email Address:

Project Information

Project Name

Location Manager

Telephone

Cell

Email Address

Type of Project Still Photography

Detailed Description of Onsite Activities (attach additional pages if needed)
NPS Form 10-930 (Rev. 08/2021) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

Page 2 of 7

RECORDS RETENTION: Unapproved (3 years). Maintain Approved applications with related permit and associated records based on appropriate item(s) in NPS

Records Schedule 1, Resources Management and Lands, (N1-79-08-1)

Location Schedule

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

Generators

Lighting Requirements

Date Location Start 

Time

End 

Time

Interior / 

Exterior

Activity (e.g., Set-up, 

Breakdown)

# of Cast 

and Crew*

Talent

Talent comprises anyone in front of the camera and includes, but is not limited to: models, hosts, correspondents, presenters, park 

visitors, cooperators, volunteers, National Park Service and concessioner staff, etc.

Do you intend to use talent? 

Yes (If yes, write a full description below of who they are and how they’ll be used. Attach additional pages if necessary).

No

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). 

Are you using generators? Quantity (if using) Size (if using)

Yes

No

Are you using lighting? Reflectors only? Description of lighting requirements (attach additional 

pages if necessary)

Yes

No

Yes

No
NPS Form 10-930 (Rev. 08/2021) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

Page 3 of 7

RECORDS RETENTION: Unapproved (3 years). Maintain Approved applications with related permit and associated records based on appropriate item(s) in NPS

Records Schedule 1, Resources Management and Lands, (N1-79-08-1)

Road Use

Road Use Schedule

Road Use Shots

Driving

Drive-by

Towing

Wet down road

Drive-ups and away

Other (please explain): 

Camera Equipment

Camera / equipment location (check all that apply) Road shoulder

Road median

Other (explain):

Types of equipment (check all that apply) Hand

Dolly with track footage

Portable crane

Tripod

Arm footage

Car mount

Dolly

Crane or jib arm

Camera car, shot maker, or process trailer

Will you require the use of roads? Do you require road closures?

Yes (If yes, please explain below)

No

Yes (If yes, please explain below)

No

Starting Date Ending Date Starting Time 

(include AM or PM)

Ending Time 

(include AM or PM)

Location
NPS Form 10-930 (Rev. 08/2021) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

Page 4 of 7

RECORDS RETENTION: Unapproved (3 years). Maintain Approved applications with related permit and associated records based on appropriate item(s) in NPS

Records Schedule 1, Resources Management and Lands, (N1-79-08-1)

Operational Information

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.

Involvement of Minors

Yes (If yes, provide the information requested below)

No

Livestock or Trained Animals

Yes (If yes, provide the information requested below)

No

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, aircraft will be used (If yes, explain)

No, aircraft won’t be used

Explanation of use

Special Effects

Including weapons, pyrotechnics, etc. Attach additional pages, if necessary.

Description of special 

effects to be used

Effects technician’s name

Technician phone 

Technician email 

License # (if applicable)

Permit # (if applicable)

Number of cars, 

SUVs, or light 

pick-up trucks

Number of vehicles 

greater than 10,000 lbs 

(class 3 or higher)

Base camp location (attach 

diagrams)

Special activities (attach 

additional pages, if necessary)

Quantity of minors Age range

Type of livestock Quantity of livestock Manner of transportation Staging/coral requirements
NPS Form 10-930 (Rev. 08/2021) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

Page 5 of 7

RECORDS RETENTION: Unapproved (3 years). Maintain Approved applications with related permit and associated records based on appropriate item(s) in NPS

Records Schedule 1, Resources Management and Lands, (N1-79-08-1)

Stunts

Will stunts be used? Yes, stunts will be used (If yes, explain)

No, stunts won’t be used

Explanation of stunts

Stunt coordinator’s name

Coordinator phone

Coordinator email

Other Hazardous Activities

Any other unusual or 

hazardous activities?

Yes (If yes, explain)

No

Explanation of activities

Activity Questions

Have you 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 obtained a permit from the National Park Service in the past? 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 photography on Federal lands? 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 on an attached 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 (If yes, explain)

No

If yes, provide a full 

description (including 

contact information) of all 

other individuals / 

companies involved with 

this project. Attach 

additional pages, as 

necessary.
NPS Form 10-930 (Rev. 08/2021) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

Page 6 of 7

RECORDS RETENTION: Unapproved (3 years). Maintain Approved applications with related permit and associated records based on appropriate item(s) in NPS

Records Schedule 1, Resources Management and Lands, (N1-79-08-1)

Contacts

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.

Name

Title

Company Name

Date

Signature

Role Name Title Telephone Cell Email address

Person on Location 

Responsible for 

Adherence to All Terms 

and Conditions of Permit

Person on Location 

Responsible for 

Coordinating Activities 

With the NPS

Company Point-ofcontact for Follow-up 

Information and Billing
NPS Form 10-930 (Rev. 08/2021) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

Page 7 of 7

RECORDS RETENTION: Unapproved (3 years). Maintain Approved applications with related permit and associated records based on appropriate item(s) in NPS

Records Schedule 1, Resources Management and Lands, (N1-79-08-1)

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 

cashier’s check, money order or personal check made payable to the National Park Service to Theodore Roosevelt Birthplace National 

Historic Site 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: The authority to collect information on the attached form is derived from 54 U.S.C. 100101.

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 54 U.S.C.103104. 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 Reston, Virginia 20192. Please do not 

send your form to this address.

INTERNAL AGENCY USE ONLY

INTERNAL AGENCY USE ONLY

Project Number/BILL:

Date Processed:

Permit Number:

Prepared By:

Organization Name: