NPS Form 10-930 (Rev. 06/2017) OMB Control No. 1024-0026

National Park Service Expiration Date 01/31/2020

APPLICATION FOR SPECIAL USE PERMIT

War in the Pacific National Historical Park

135 Murray Blvd. Suite 100

Hagatna, Guam 96910

333-4055/51/52

RECORDS RETENTION: TEMPORARY. Destroy/delete 3 years after closure. (NPS Records Schedule, Resource Management and Page 1 of 5

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 $20.00 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. 

Applicant Name Company/Organization Name

 

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

 

Description of Proposed Activity (attach diagram and/or additional pages, if necessary)

 

Requested Location

 
NPS Form 10-930 (Rev. 06/2017) OMB Control No. 1024-0026

National Park Service Expiration Date 01/31/2020

Page 2 of 5

Applicant Name Company/Organization Name

Set-Up Begins Activity Begins Activity Ends Removal Completed

Date Date Date Date 

Time AM PM Time AM PM Time AM PM Time AM PM

Date Date Date Date 

Time AM PM Time AM PM Time AM PM Time AM PM

Date Date Date Date 

Time AM PM Time AM PM Time AM PM Time AM PM

Maximum Number of 

Participants (Best Estimate)

Maximum Number of Vehicles (attach parking plan)

Cars Vans/Light Trucks Utility Vans/Trucks Buses/Oversized 

Vehicles

 

Support equipment (list all equipment; attach additional pages if necessary)

 

List support personnel including addresses and telephones; attach additional pages if necessary

Name Address Cell Phone Number

 

 

 

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

permitted activity:

Cell Phone Number

 

Is this an exercise of First Amendment Rights? Yes No

Have you visited the requested area? Yes No

Have you obtained a permit from the National Park Service in the past? 

 (If yes, provide a list of permit dates and locations on a separate page.) Yes No

Do you plan to advertise or issue a press release before the event? Yes No

Will you distribute printed material? Yes No

Is there any reason to believe there will be attempts to disrupt, protest or prevent your event? 

 (If yes, please explain on a separate page.) Yes No

Do you intend to solicit donations or offer items for sale? (These activities may require an additional permit.) Yes No

You are encouraged to attach additional pages with information useful in evaluating your permit request including: staging, 

sound systems, parking plan, security plans, sanitary facilities, crowd control, emergency medical plan, use of any building, site cleanup, etc.

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 statements have been given.

Printed Name Title

 

Signature Date

 
NPS Form 10-930 (Rev. 06/2017) OMB Control No. 1024-0026

National Park Service Expiration Date 01/31/2020

Page 3 of 5

NOTICES

IMPORTANT NOTICE TO APPLICANT

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 War in the Pacific NHP 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

General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals 

completing this application. 

Authority: The authority to collect information on the attached form is derived from Title 31, United States Code, Section 7701. 

Purposes and Uses: The information being collected to allow the park manager to make a value judgment on whether or not to allow 

the requested use. Information from the application may be transferred to appropriate Federal, State, and local agencies, when 

relevant to civil, criminal or regulatory investigations or prosecutions.

Effects of Nondisclosure: It is in your best interest to answer all of the questions. The U.S. Criminal Code, Title 18 U.S.C. 1001, 

provides that knowingly falsifying or concealing a material fact is a felony that may result in fines of up to $10,000 or 5 years in prison, 

or both. Deliberately and materially making false or fraudulent statements on this form will be grounds for not granting you a Special 

Use Permit

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 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 10-930 (Rev. 06/2017) OMB Control No. 1024-0026

National Park Service Expiration Date 01/31/2020

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SPECIAL USE PERMIT RULES AND REGULATRION 

• Activity that prevent, disrupt or interfere with park visitors’ access to exhibits, monuments, historical structures, or WWII

military equipment are prohibited.

• Motorized vehicles are prohibited on the grass and pathways for all purposes including loading or unloading.

• All debris, litter, and garbage generated by activity must be removed from the park.

• Permittee is responsible for cleaning barbecue grills and for the removal of charcoal. 

• Operation of any type of portable motor or engine, or device powered by a portable motor or engine, is prohibited.

• Organized sports activities are prohibited within park boundaries. This included baseball leagues, soccer team, ect.

• The use of or possession of weapons and fireworks are prohibited.

• For your safety, tunnels and caves are off-limits.

• Camping overnight is prohibited.

• Ground fires are prohibited.

• Removing, cutting, or otherwise damaging natural resources (vegetation, wood, sand) within the park is prohibited. 

• Climbing on trees or historical objects is prohibited. 

• Motor boats are prohibited within the Asan reef area. This is for your safety as unpredictable currents are dangerous.

• Jumpers and bouncers are prohibited. 

• Restroom facilities are closed between 5:00-5:30 pm daily.

PERMITTEE SIGNATURE: _________________________________

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

INTERNAL AGENCY USE ONLY

 

Project Number/BILL Date Processed

 

Permit Number Prepared By

 

Organization Name

 
NPS Form 10-930 (Rev. 06/2017) OMB Control No. 1024-0026

National Park Service Expiration Date 01/31/2020

Page 5 of 5