Application For Special Use Permit - New York National Park Service (Page 2 of 3) in pdf

Application For Special Use Permit - New York National Park Service Page 2

_______Cars

_______Vans/lt.trucks

_______Utl.vans/trucks

_______Buses/oversized

vehicles

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

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

Individual in charge of activity on-site (include cell phone number) and authorized to make decisions

related to the permitted activity:

Is this an exercise of First Amendment Rights?

Have you visited the requested area?

Have you obtained a permit from the National Park Service in the past?

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

Do you plan to advertise or issue a press release before the event?

Will you distribute printed material?

Is there any reason to believe there will be attempts to disrupt, protest or

prevent your event? (If yes, please explain on a separate page.)

Do you intend to solicit donations or offer items for sale?

(These activities may require an additional permit.)

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.

Signature

Date ___________________

Printed Name_________________________________ Title_______________________

Note: 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 credit card payment,

cashier’s check, money order or personal check made payable to National Park Service to Special

Use Permit Coordinator at the Park address found on the first page of this application.

NPS Form 10-930 REV 06/2013

OMB Control No. 1024-0026

Expires 08/31/2016

Application For Special Use Permit - New York National Park Service Page 2