Nps Form 10-550 - Commercial Use Authorization Application (Page 7 of 12) in pdf

NPS Form 10-550 (Rev. 11/2016)

OMB Control No. 1024-0268

National Park Service

Expiration Date: 11/15/2019

13. Violations:

To your knowledge, have you, your company, or any current or proposed employees been convicted or fined for violations of State,

Federal, or local law within the last 5 years? Are you, your company, or any current or proposed employees now under

investigation for any violations of State, Federal, or local law or regulation? See instructions.

If “Yes”, please provide the following information. Attach additional pages, if necessary.

Yes

Date of violation or incident under investigation:

Name of business or person(s) charged:

Please identify the law or regulation violated or under investigation:

Please identify the State, municipality, or Federal agency that initiated the charges:

Additional Detail (optional):

(Results) Action Taken by Court:

14. Fee:

Please include the non-refundable, 2-year Application/Administrative Fee of $ 200.00, in the form of a check or money order made

payable to the National Park Service.

15. Signature:

False, fictitious or fraudulent statements of representations made in this application may be grounds for denial or revocation of the

Commercial Use Authorization and may be punishable by fine or imprisonment (U.S. Code, Title 18, Section 1001). All information

provided will be considered in reviewing this application. Authorized Agents must attach proof of authorization to sign below.

By my signature, I hereby attest that all my statements and answers on this form and any attachments are true, complete, and

accurate to the best of my knowledge.

Signature

Date

_________________________________________________________

Printed Name

Title

NOTICES

Privacy Act Statement

Authority: The authority to collect information on the attached form is derived from 16 U.S.C. 5966, Commercial Use Authorizations.

Purpose: The purposes of the system are (1) to assist NPS employees in managing the National Park Service Commercial Services program allowing

commercial uses within a unit of the National Park System to ensure that business activities are conducted in a manner that complies with Federal laws

and regulations; (2) to monitor resources that are or may be affected by the authorized commercial uses within a unit of the National Park System; (3) to

track applicants and holders of commercial use authorizations who are planning to conduct or are conducting business within units of the National Park

System; and (4) to provide to the public the description and contact information for businesses that provide services in national parks.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C.552a(b) of the Privacy Act, records or information contained in this

system may be disclosed outside the National Park Service as a routine use pursuant to 5 U.S.C. 552a(b)(3) to other Federal, State, territorial, local,

tribal, or foreign agencies and other authorized organizations and individuals based on an authorized routine use when the disclosure is compatible with

the purpose for which the records were compiled as described under the system of records notice for this system.

Disclosure: Providing your information is voluntary, however, failure to provide the requested information may impede the processing of your

commercial use authorization application.

Paperwork Reduction Act Statement

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), please note the following. This information collection is authorized by The

Concession Management Improvement Act of 1998 (54 USC 101911). Your response is required to obtain or retain a benefit in the form of a

Commercial Use Authorization. We will use the information you submit to evaluate your ability to offer the services requested and to notify the public

what services you will offer. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a

currently valid Office of Management and Budget control number. OMB has assigned control number 1024-0268 to this collection.

Estimated Burden Statement

We estimate that it will take approximately 2.5 hours to prepare an application, including time to review instructions, gather and maintain data, and

complete and review the proposal. Send comments regarding this burden estimate or any other aspect of this collection of information, including

suggestions for reducing this burden, to the Information Collection Officer, National Park Service, 12201 Sunrise Valley Drive, MS-242, Reston, VA

20192. Please do not send your completed form to this address; but rather to the address at the top of the form.

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Nps Form 10-550 - Commercial Use Authorization Application Page 7

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