NPS Form 10-932 (Rev. 06/2017) OMB Control No. 1024-0026 

National Park Service Expiration Date 01/31/2020

APPLICATION FOR SPECIAL USE PERMIT

COMMERCIAL FILMING / STILL PHOTOGRAPHY

(Long Form)

Flagstaff Area Monuments

(Sunset Crater-Walnut Canyon-Wupatki)

6400 N. U.S. Hwy 89 

Flagstaff, AZ 86004 

Nicholas Poulos, Special Use Coordinator 

Email: Nicholas_a_poulos@nps.gov

RECORDS RETENTION: TEMPORARY. Destroy/delete 3 years after closure. (NPS Records Schedule, Resource Management and Page 1 of 8

Lands (Item 1D) (N1-79-08-1)) 508

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

nonrefundable processing fee of $100.00 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 Name Company/Organization Name

Social Security Number* Tax Identification Number*

Street Address Street Address

City State Zip Code Country City State Zip Code Country

Telephone Number Contact Name

Cell Phone Number Telephone Number

Fax Number Fax Number

Email Address Email Address

PROJECT INFORMATION

Project Name Telephone Number Cell Phone Number

Location Manager Email Address

Type of Project

 Video/Motion Picture/Movie Still Photography

Detailed Description of Onsite Activities (attach additional pages, if necessary)

LOCATION SCHEDULE

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

Date Location Start Time End time

Interior/

Exterior 

Activity: Set-Up/Film/

Non-Filming/Breakdown 

Number of

Cast/Crew* 
NPS Form 10-932 (Rev. 06/2017) OMB Control No. 1024-0026

National Park Service Expiration Date 01/31/2020

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Applicant Name Company/Organization Name

NPS Form 10-932 (Rev. 06/2017) OMB Control No. 1024-0026

National Park Service Expiration Date 01/31/2020

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TALENT

Talent comprises 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 concessioner staff, etc.

Do you intend to utilize talent? Yes No If “Yes”, provide a full description below of who they are and how they will be 

utilized. (attach additional pages, if necessary)

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). 

Generators? If “Yes”, provide quantity and size. Yes No Quantity Size

LIGHTING REQUIREMENTS

Lighting? Yes No (If “Yes”, explain below) Reflectors Only? Yes No

Description of lighting requirements (attach additional pages, if necessary). 

ROAD USE

Will you require the use of roads? Yes No If “Yes”, please explain: 

Do you require road closures? Yes No 

If “Yes”, please provide the following information (attach additional pages, if necessary)

Starting 

Date

Ending 

Date Starting Time Ending Time Location

AM AM

PM PM

AM AM

PM PM

AM AM

PM PM

AM AM

PM PM

AM AM

PM PM

Types of Shots: Driving Drive-by Towing Wet down road

Drive-ups and away Other (explain): 
NPS Form 10-932 (Rev. 06/2017) OMB Control No. 1024-0026

National Park Service Expiration Date 01/31/2020

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CAMERA EQUIPMENT

Camera/Equipment 

Location:

(Check all that apply)

Road shoulder Road median

Other (explain): 

Types of Equipment:

(Check all that apply)

Hand Tripod Dolly

Dolly w/track footage Arm footage Crane or jib arm

Portable crane Car mount Camera car, shot maker, or process trailer

OPERATIONAL INFORMATION

NUMBER OF VEHICLES

NOTE: 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.

Cars, SUVs, or light pick-up trucks Vehicles greater than a 10,000 lbs. (class 3 or higher)

BASE CAMP LOCATION (attach diagrams)

SPECIAL ACTIVITIES (attach additional pages, if necessary) 

INVOLVEMENT OF MINORS

Will children be involved? Yes No If “Yes”, provide number of children and age range. Quantity Age Range

LIVESTOCK OR TRAINED ANIMALS

Will livestock or trained animals be used? Yes No If “Yes”, provide the following:

Type Quantity Manner of 

Transportation Staging/Coral Requirements

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 No If “Yes”, explain below (attach additional pages, if necessary)

SPECIAL EFFECTS (including weapons, pyrotechnics, etc.) (attach additional pages, if necessary) 

Effects Technician’s Name Contact Phone Number Email Address

 

License # (if applicable) Permit # (if applicable)

 

STUNTS

Will stunts be used? Yes No If “Yes”, explain below (attach additional pages, if necessary)

Stunt Coordinator Contact Phone Number Email Address

 

OTHER OR HAZARDOUS ACTIVITIES

Any other unusual or hazardous activities? Yes No If “Yes”, explain below (attach additional pages, if necessary)
NPS Form 10-932 (Rev. 06/2017) OMB Control No. 1024-0026

National Park Service Expiration Date 01/31/2020

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OPERATIONAL INFORMATION

Have you physically 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 had previous permits from the National Park Service? 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 filming on Federal lands? Yes No

 Are there any pending Federal investigations against you which involve a commercial filming activity? 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 (attach additional 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 No 

If “Yes”, provide a full description (including contact information) of all other individuals/companies involved with this project 

(attach additional pages, as necessary)

CONTACTS

Person on Location Responsible for Adherence to All Terms and Conditions of Permit:

Name Title

 

Telephone Number Cell Phone Number Email Address

 

Person on Location Responsible for Coordinating Activities With the NPS:

Name Title

 

Telephone Number Cell Phone Number Email Address

 

Company Point-of-contact for Follow-up Information and Billing: 

Name Title

 

Telephone Number Cell Phone Number Email Address

 

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. 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.

Printed Name Title Company Name

Signature Date
NPS Form 10-932 (Rev. 06/2017) OMB Control No. 1024-0026 

National Park Service Expiration Date 01/31/2020 

Page 5 of 8

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: 

credit card payment, cashier’s check, money order or personal check made payable to the National Park Service] to ATTN: Mike 

Haubert, Special Use Coordinator at the 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: 16 U.S.C. 1, National Park Service Organic Act; 16 U.S.C. 3, Rules and regulations of national parks, reservations, and 

monuments; timber; leases, 16 U.S.C. 3a, Recovery of costs associated with special use permits; and 16 U.S.C. 460i–6d, Commercial 

Filming. 

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 31 U.S.C. 7701. 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, Mail Stop 242, Reston, VA 20192. 

Please do not send your form to this address.
NPS Form 10-932 (Rev. 06/2017) OMB Control No. 1024-0026 

National Park Service Expiration Date 01/31/2020

Page 6 of 8

Credit Card Authorization

All credit card information is protected under the Privacy Act of 1974

Applicant Name Cardholder Name (as it appears on card)

 Same as “Applicant”

Company Name (if applicable) Telephone Number Cell Phone Number

 

Email Address Federal Taxpayer Identification or Social Security Number

 

Credit Card Billing Address

 

City State Zip Code Country

 

Amount to be Billed to Card

Application Cost $ Location Fee $ Cost Recovery $ Total $ 

Type of Credit Card Credit Card Number Expiration Date Security 

Code

American 

Express Discover Mastercard Visa 

I hereby authorize my card to be charged the amount indicated above in connection with the issuance of the requested Special Use 

Permit:

Cardholder Authorized Signature Date

 

INTERNAL AGENCY USE ONLY

 

Project Number/BILL Date Processed

 

Permit Number Prepared By

 

Organization Name