NPS Form 10-930s (Rev. 08/2019) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

APPLICATION FOR SPECIAL USE PERMIT

SHORT FORM

Tonto National Monument

26260 N AZ Hwy 188

Roosevelt, AZ 85545

928-467-2241

Page 1 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).

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

A nonrefundable processing fee of $50 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 Telephone Number

Organization Cell Phone Number

Social Security Number or Tax ID number Fax Number

Email Address

Street Address

City State Zip Code Country

Proposed Activity

Preferred Date Preferred Location Preferred Time

Alternate Date(s)* Alternate Location(s)* Alternate Time(s)*

* Alternatives will be considered if first choice is not available.

Maximum Number of Participants Maximum Number of Vehicles

List of Equipment

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

permitted activity:

Cell Phone Number

Have you visited the requested area? Is this an exercise of a First Amendment rights?

Yes No Yes No
NPS Form 10-930s (Rev. 08/2019) 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).

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 Tonto National Monument 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 54 U.S.C. 100101, Promotion and regulation; 54 

U.S.C. 100751(a), Regulations; 54 U.S.C. 103104, Recovery of costs associated with special use permits; and 54 U.S.C 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 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.

INTERNAL AGENCY USE ONLY 

Project Number/BILL Date Processed

Permit Number Prepared By

Organization Name
NPS Form 10-930s (Rev. 08/2019) 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