Application For Special Use Permit - New York National Park Service

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National Park Service
Women’s Rights National Historical Park
136 Fall Street, Seneca Falls, NY 13148
315-568-2991
Application for Special Use Permit
Please supply the information requested below. Attach additional sheets, if necessary, to provide
required information. A nonrefundable processing fee of $150.00 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:
Company/Organization Name:
Social Security #:
Tax ID #
Street/Address:
Street/Address:
City/State/Zip Code:
City/State/Zip Code:
Telephone #:
Contact name:
Cell phone #:
Telephone #:
Fax #:
Fax#:
Email:
Email:
Description of Proposed Activity (attach diagram, attach additional pages if necessary):
Requested Location(s):
______________________________________________________________________
DATE(S)
Set up begins:
Activity begins:
Activity ends:
Removal completed
(date and time)
(date and time)
(date and time)
(date and time)
Maximum Number of Participants
(Please provide best estimate)
Maximum Number of vehicles: (attach parking plan)
1
NPS Form 10-930 REV 06/2013
OMB Control No. 1024-0026
Expires 08/31/2016

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