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

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.

Notice to 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information from your check to make an electronic fund transfer, funds may be withdrawn from your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.

NOTICES

Privacy Act Statement: The Privacy Act of 1974 (5 U.S.C. 552a) provides that you be furnished with

the following information in connection with information required by this application. This information

is being collected to allow the park manager to make a value judgment on whether or not to allow the

requested use. 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 (31 U.S.C.

7701). Information from the application may be transferred to appropriate Federal, State, and local

agencies, when relevant to civil, criminal or regulatory investigations or prosecutions.

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 30

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 other aspect of this

form to the Information Collection Clearance Officer, National Park Service, 1849 C Street NW.

(1237), Washington, D.C. 20240

Title 18 U.S.C. Section 1001 makes it a crime for any person to knowingly and willfully make to any

department or agency of the United States any false, fictitious, or fraudulent statements or

representations as to any mater within its jurisdiction.

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 3