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

National Park Service Expiration Date 11/30/2023

APPLICATION FOR SPECIAL USE PERMIT 

SHORT FORM

Tumacácori National Historical Park

P.O. Box 8067

Tumacácori, AZ 85640

520-377-5060

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 $130 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. 

Applicant Information

Applicant Name: Telephone Number:

Organization: Cell Phone Number:

Social Security Number or Tax ID Number: Fax Number:

Email Address: Street Address:

City: State:

Zip Code: Country:

Activity Details

Description of Proposed Activity (Attach Additional Sheets if More Space is Needed)

* Alternatives will be considered if first choice is not available

Participants, Vehicles, & Equipment

If using any vehicles, attach a parking plan to this form.

Type Maximum Number

Participants (best estimate)

Vehicles

Individual in Charge

Individual in charge of activity onsite who is authorized to make decisions related to the permitted activity

Name Cell Phone Number

Activity Questions

Is this an exercise of First Amendment Rights? Yes No

Have you visited the requested area? Yes No

Date Location Time

Preferred Date: Preferred Location: Preferred Time:

Alternate Date(s): Alternate Location(s): Alternate Time(s):

List of Equipment (Attach Additional Sheets if More Space is Needed)
NPS Form 10-930 (Rev. 08/2021) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

Page 2 of 3

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)

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

Signature

Date

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. Mail the completed application to the park address found on the first page of this 

application, C/O: Special Use Permit Coordinator. The permit coordinator will create an e-Bill, a convenient and secure online payment 

option, the e-Bill will be sent to you via email with instructions on how to process a secure payment online through pay.gov. A 

notification will be sent to the permit coordinator when an e-Bill payment has been processed.

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.

Estimated Burden Statement

Public reporting burden for this form is estimated to average 15 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.
NPS Form 10-930 (Rev. 08/2021) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

Page 3 of 3

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)

INTERNAL AGENCY USE ONLY

Project Number/BILL:

Date Processed:

Permit Number:

Prepared By:

Organization Name: