Form 10-932 - Application For Special Use Permit Commercial Filming/still Photography - National Park Of American Samoa
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5National Park Service
National Park of American Samoa
MHJ Building, 2nd Floor
Pago Pago, AS 96799
684-633-7082
Application for Special Use Permit
Commercial Filming/Still Photography
Please supply the information requested below. Attach additional sheets, if necessary, to provide required
information. A nonrefundable processing fee of $100.00 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:
Applicant Company:
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:
Project name:
Telephone #:
Location manager:
Cell phone #:
Email:
TYPE OF PROJECT: o Still photography
o video/motion picture/film
Detailed description of onsite activities: (attach additional pages as necessary)
NPS Form 10-932 rev 06/2013
OMB Control No. 1024-0026
Expires 08/31/2016
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