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

National Park Service Expiration Date 11/30/2023

APPLICATION FOR SPECIAL USE PERMIT

Theodore Roosevelt Birthplace National Historic Site

Attention: Business Management Program 

26 Wall Street, New York, NY 10005 

masi_special_park_use@nps.gov

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 $0.00 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 Information Company/Organization Information

Applicant Name: Company/Organization Name:

Social Security Number*: Tax Identification Number*:

Street Address: Street Address:

City: City:

State: State:

Zip Code: Zip Code:

Country: Country:

Telephone Number: Telephone Number:

Cell Phone Number: Contact Name:

Fax Number: Fax Number:

Email Address: Email Address:

Activity Details

Description of Proposed Activity (attach diagram and/or additional pages, if necessary)
NPS Form 10-930 (Rev. 08/2021) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

Page 2 of 5

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)

Location Details

Requested Location

Equipment Details

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

Timing

Set-Up Begins Activity Begins Activity Ends Removal Completed

Date:

Time:

AM PM

Date:

Time:

AM PM

Date:

Time:

AM PM

Date:

Time:

AM PM

Date:

Time:

AM PM

Date:

Time:

AM PM

Date:

Time:

AM PM

Date:

Time:

AM PM

Date:

Time:

AM PM

Date:

Time:

AM PM

Date:

Time:

AM PM

Date:

Time:

AM PM

Vehicles & Participants

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

Type Maximum Number

Participants (best estimate)

Cars

Vans/Light Trucks

Utility Vans/Trucks

Buses/Oversized Vehicles

Support Personnel 

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

Name Address Cell Phone Number

Individual in Charge

Individual in charge of activity onsite who is authorized to make decisions related to the permitted activity
NPS Form 10-930 (Rev. 08/2021) OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

Page 3 of 5

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)

Name Cell Phone Number

Activity Questions

Is this an exercise of First Amendment Rights? Yes No

Have you visited the requested area? Yes No

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

Have you obtained a permit from the National Park Service in the past? Yes No

(If yes, provide a list of permit dates and locations on a separate page.)

Will you distribute printed material? Yes No

Is there any reason to believe there will be attempts to disrupt, protest or prevent your event? Yes No

(If yes, please explain on a separate page.)

Do you intend to solicit donations or offer items for sale? Yes No

(These activities may require an additional permit.)

Is this permit to carry out a Good Samaritan Search and Recovery Mission? 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 clean-up, 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.

Name

Title

Signature

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

National Park Service Expiration Date 11/30/2023

Page 4 of 5

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

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 and sent to Theodore Roosevelt National Historic Site 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

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 100905 Commercial Filming.

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

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 agencysponsored 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 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 5 of 5

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: