NPS Form 10-931 (Rev. 08/2021)		OMB Control No. 1024-0026

National Park Service		Expiration Date 11/30/2023

NPS Form 10-931 (Rev. 08/2021)		OMB Control No. 1024-0026

National Park Service		Expiration Date 11/30/2023

NPS Form 10-931 (Rev. 08/2021)		OMB Control No. 1024-0026

National Park Service		Expiration Date 11/30/2023

Please supply the information requested below.  **Attach additional sheets, if necessary, to provide required information.**  A nonrefundable processing fee of $50.00 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.**

# **Project Information**

# **Type of Project**

|_| Still Photography

# **Location Schedule**

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

# **Number of Vehicles**

# **Activity Questions**Have you 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 obtained a permit from the National Park Service in the past?					|_| 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 photography on Federal lands?				 	|_| 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 on an attached sheet				|_| Yes  |_| No

# **Contacts**Person on location responsible for adherence to all terms & conditions of the permit

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.

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# **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 money order or personal check made payable to the **National Park Service** to Weir Farm 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**

**Authority:** The authority to collect information on the attached form is derived from 54 U.S.C. 100101.

**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**

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)	

Page 4 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)

		Page 3 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)

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