NPS Form 10-931 rev 02/2018 OMB Control No. 1024-0026

National Park Service

Wrangell-St. Elias National Park and Preserve 

PO Box 439, Copper Center, Alaska 99573

907-822-7206

Application for Special Use Permit Commercial 

Filming/Still Photography (5 or fewer crew)

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

information. A nonrefundable processing fee of $200.00 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 as also insured.

Enter either a social security number OR a tax ID number: we do not require both.

Applicant Name: 

Social Security #:

Street/Address: 

City/State/Zip Code:

Telephone #:

Cell phone #:

Fax #:

Email:

Project name:

Location manager

Applicant Company:

Tax ID #:

Street/Address: 

City/State/Zip Code:

Contact name: 

Telephone #:

Fax #:

Email:

Telephone #:

Cell phone #:

E-mail:

TYPE OF PROJECT: stillphotography video / motion picture / film 

Detailed description of onsite activities (attach additional pages as necessary): 

LOCATION SCHEDULE 

Each date and each location must have an individual entry – use additional pages as necessary.

Date Location Start Time End Time Interior /

Exterior

Activity: Set-Up/ 

Film / NonFilming 

/Breakdown

# of Cast &

Crew*

* number in this column should include all individuals present at the location
NPS Form 10-931 rev 02/2018 OMB Control No. 1024-0026

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): 

Number of Vehicles: 

Car, SUV or light truck Vehicles greater than a 10,000 lbs. (class 3 or higher) 

Have you physically visited the requested area? Y N 

Do you plan on advertising or issuing a press release for this activity? Y N 

When answering yes to any of the following questions, provide additional information:

Do you have, or are you applying for, a permit with another Federal, State or local 

Y N 

Y N 

Y N 

Y N 

Y N 

Y N 

agency for this activity?

Have you had previous permits from the National Park Service? 

Have you ever been denied a permit or had a permit revoked by a Federal agency? 

Have you forfeited a bond or other security for filming on Federal lands?

Are there any pending Federal investigations against you which

involved a commercial filming activity?

Do you anticipate any security concerns? If yes, explain.

CONTACTS: 

Person on location responsible for adherence to all terms & conditions of the permit: 

Name: Title:

Phone: Cell Phone: 

 

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. 

Signature: Print Name: Date: 

Title: Company Name:

Note: 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 $200 application fee in the form of a credit card, cashier’s check, money order or 

personal check made payable to National Park Service to Special Use Permits at the Park address found on 

the first page of this application. The application may be paid online at pay.gov.

If your request is approved, a permit containing applicable terms and conditions will be sent to 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. 

Notice to 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 
NPS Form 10-931 rev 02/2018 OMB Control No. 1024-0026

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. 

NOTICES 

Privacy Act Statement: The Privacy Act of 1974 (5 U.S.C. 552a) provides that you be furnished with the 

following information in connection with information required by this application. This information is being 

collected to allow the park manager to make a value judgment on whether or not to allow the requested use. 

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 (31 U.S.C. 7701). Information from the application 

may be transferred to appropriate Federal, State, and local agencies, when relevant to civil, criminal or 

regulatory investigations or prosecutions. 

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, 1849 C Street NW (1237), Washington, D.C. 20240. 

Title 18 U.S.C. Section 1001 makes it a crime for any person knowingly and willfully to make to any 

department or agency of the United States any false, fictitious, or fraudulent statements or representations as 

to any mater within its jurisdiction.