Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data 

sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other 

aspect of this collection of information, including suggestions for reducing this burden, to the Office of Facilities Management and Services Programs (PM), GSA Public Buildings 

Service, Washington, DC 20405.

DATE SIGNED

GENERAL SERVICES ADMINISTRATION GSA 3453 (REV. 1/2016)

PART II - PERMIT (TO BE COMPLETED BY GSA ONLY)

DESIGNATED BUILDING AND AREA, ACTUAL DATES AND HOURS, FOR WHICH ACTIVITY APPROVED

BUILDING AREA FROM TO HOURS

SIGNATURE

GSA APPROVING OFFICIAL

NAME OF OFFICIAL

PROPOSED BUILDING

PROPOSED DATES AND HOURS DURING WHICH THE ACTIVITY IS TO BE CARRIED OUT

FROM TO HOURS

APPROXIMATE NUMBER OF PERSONS TO 

BE ENGAGED IN THIS ACTIVITY (If known)

IMPORTANT: If applicant purports to represent an organization, a letter or other documentation that the applicant has authority to 

represent that organization is required to be submitted with this form.

APPLICANTS PROPOSING TO ENGAGE IN THE SOLICITATION OF FUNDS MUST CHECK ONE OF THE FOLLOWING STATEMENTS:

I HEREBY CERTIFY THAT:

I represent and will be soliciting funds for the sole benefit of a religion or religious group;

My organization has received an official Internal Revenue Service (IRS) ruling or letter of determination stating that the 

organization or its parent organization qualifies for tax-exempt status under 26 U.S.C. 501(c)(3), (c)(4), or (c)(5); or

My organization has applied to the IRS for a determination of tax-exempt status under 26 U.S.C. 501(c)(3), (c)(4), or (c)(5), 

and that the IRS has not yet issued a final administrative ruling or determination of such status.

CERTIFICATION: I CERTIFY that the above information is true and correct.

PROPOSED AREA

SIGNATURE OF APPLICANT DATE SIGNED

MAILING ADDRESS

STREET

CITY STATE ZIP CODE

SPONSOR, PROMOTER OR CONDUCTOR OF PROPOSED ACTIVITY

NAME OF PERSON OR ORGANIZATION

TELEPHONE NUMBER

AREA CODE PHONE EXTENSION

MAILING ADDRESS

STREET

CITY STATE ZIP CODE

SUPERVISION OF/AND RESPONSIBILITY FOR THE PROPOSED ACTIVITY

NAME OF PERSON

TELEPHONE NUMBER

AREA CODE PHONE EXTENSION

MAILING ADDRESS

STREET

CITY STATE ZIP CODE

DESCRIPTION OF PROPOSED ACTIVITY

APPLICATION/PERMIT FOR USE OF SPACE 

IN PUBLIC BUILDINGS AND GROUNDS

OMB Control Number: 3090-0044 

Expiration Date: 5/31/2025

PART I - APPLICATION

APPLICANT

FIRST NAME MIDDLE LAST NAME

TELEPHONE NUMBER EXTENSION E-MAIL ADDRESS

INSTRUCTIONS: This form allows the Applicant to request the use of federally owned property in accordance with 40 U.S.C. § 581(h) and Federal Management Regulation 41 

C.F.R. part 102-74, subpart D. The Applicant must accurately describe the proposed use and, if approved, the form will serve as the permit for that use. Please submit the form 

to the federal property manager responsible for the property. 

Note: If the proposed use is a farmers market, the Applicant must confer with the Federal property manager and regional counsel to determine whether a permit (GSA 3453); a 

license (GSA 1582); or an outlease is the appropriate vehicle for the specific circumstances of each market.
DATE SIGNED

GSA 3453 (REV. 1/2016) BACK

PART III - CONDITIONS

By submitting this form, Applicant agrees to the following terms and conditions: 

 

Applicant will conduct the proposed activity strictly in accordance with the description of the activity in this permit. 

 

Applicant must submit, as part of this permit, a copy, sample or accurate description of any materials proposed for distribution at 

the event. 

 

Unless otherwise agreed to, in writing, by GSA and incorporated into this permit, the Applicant assumes all responsibility for, and 

costs and expenses associated with, clean-up of the grounds, providing trash containers and disposal of trash, as well as any 

additional security, electrical and water or related services needed to support the activity. Portable restroom facilities may be 

authorized, at Applicant's sole cost and expense, if Applicant arranges for the removal before the beginning of the next business 

day. 

 

GSA will neither store nor assume any responsibility for any materials that are used for an event. 

 

By signing the permit application and without the need for further documentation, Applicant hereby indemnifies and saves 

harmless the United States, its agents and employees, in both their personal and official capacities, against any and all loss, 

damage, claim, or liability whatsoever, due to personal injury or death, or damage to property of the Federal Government or 

others, directly or indirectly, due to the exercise by Applicant of the privilege granted by this permit, or any act or omission of 

Applicant, including failure to comply with the obligations of this permit. 

 

In keeping with federal policy regarding retention of records associated with federal contracts and the like, GSA will retain a copy 

of the permit for three (3) years from the date of issuance. 

 

Special terms and conditions related to this permit are listed below (and continued on the following page(s), if necessary): 

SIGNATURE OF APPLICANT

If the request to use federal space is denied or an issued permit is cancelled, the Applicant may appeal within 5 calendar days of the 

notification of disapproval or cancellation to the GSA Regional Administrator or his/her designee. For more information about how to 

request the use of Federal property under 40 U.S.C. § 581(h) and Federal Management Regulation 41 C.F.R. part 102-74, subpart D, 

please contact GSA's Office of Facilities Management and Services Programs (PM), 1800 F Street, NW, Washington, DC 20405 or visit 

www.gsa.gov