Form Gsa 3453 - Application/permit For Use Of Space In Public Buildings And Grounds 2009
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2APPLICATION/PERMIT FOR USE OF SPACE
OMB Number: 3090-0044
IN PUBLIC BUILDINGS AND GROUNDS
Expires: 10/31/2012
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.
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.
PART I - APPLICATION
APPLICANT
MAILING ADDRESS
FIRST NAME
MIDDLE
LAST NAME
STREET
TELEPHONE NUMBER
EXTENSION
E-MAIL ADDRESS
CITY
STATE
ZIP CODE
SPONSOR, PROMOTER OR CONDUCTOR OF PROPOSED ACTIVITY
NAME OF PERSON OR ORGANIZATION
MAILING ADDRESS
STREET
TELEPHONE NUMBER
AREA CODE
PHONE
EXTENSION
CITY
STATE
ZIP CODE
SUPERVISION OF/AND RESPONSIBILITY FOR THE PROPOSED ACTIVITY
NAME OF PERSON
MAILING ADDRESS
STREET
TELEPHONE NUMBER
AREA CODE
PHONE
EXTENSION
CITY
STATE
ZIP CODE
DESCRIPTION OF PROPOSED ACTIVITY
PROPOSED BUILDING
PROPOSED AREA
APPROXIMATE NUMBER OF PERSONS TO
PROPOSED DATES AND HOURS DURING WHICH THE ACTIVITY IS TO BE CARRIED OUT
BE ENGAGED IN THIS ACTIVITY (If known)
FROM
TO
HOURS
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.
SIGNATURE OF APPLICANT
DATE SIGNED
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
GSA APPROVING OFFICIAL
SIGNATURE
NAME OF OFFICIAL
DATE SIGNED
GENERAL SERVICES ADMINISTRATION
GSA 3453 (REV. 10/2009)
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