Nps Form - Application Requirements For A Commercial Filming/still Photography Permit - United States Department Of The Interior Page 3

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Description of equipment, backdrops, sets, props (attach additional pages if necessary). Please note if any
of the following will be included: weapons, animals, minors, nudity):
Number of Vehicles:
Car, SUV or light truck _________
Vehicles greater than a 10,000 lbs. (class 3 or higher) ___________
Have you physically visited the requested area?
Y
N
Do you plan on advertising or issuing a press release for this activity?
Y
N
When answering yes to any of the following questions, provide additional information:
Do you have, or are you applying for, a permit with another Federal, State or local
agency for this activity?
Y
N
Have you had previous permits from the National Park Service?
Y
N
Have you ever been denied a permit or had a permit revoked by a Federal agency?
Y
N
Have you forfeited a bond or other security for filming on Federal lands?
Y
N
Are there any pending Federal investigations against you which
involved a commercial filming activity?
Y
N
Do you anticipate any security concerns? If yes, explain.
Y
N
CONTACTS:
Person on location responsible for adherence to all terms & conditions of the permit:
Name: ________________________________ Title: _______________________
Phone: ____________ Cell Phone: ____________
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 false statements have been given.
Signature: ____________________ Print Name: ______________________ Date: ___________
Title: __________________________
Company Name: ____________________________
******************************************************************************
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, cashier’s check, money
order
or
personal
check
made
payable
to
National
Park
Service
to
___________________________________ at the Park address found on the first page of this application.
If your request is approved, a permit containing applicable terms and conditions will be sent to 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.
NPS Form 10-931 rev 06/2013
OMB Control No. 1024-0026
Expires 08-31-2016

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