Nps Form - Application Requirements For A Commercial Filming/still Photography Permit - United States Department Of The Interior Page 4
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4Credit Card Authorization: All credit card information is protected under the Privacy Act.
Name as it appears on the card (print clearly): Credit card payments may be made at
(Circle): VISA MasterCard Discover No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Exp. _ _ / _ _ Security Code _ _ _
_
Total Amount Authorized: $________
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to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day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 15 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 aspects 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 knowingly and willfully to 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 10-931 rev 06/2013
OMB Control No. 1024-0026
Expires 08-31-2016
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