Form 10-931 - Application For Special Use Permit Commercial Filming/still Photography - National Park Service Page 2

*   n umber   i n   t his   c olumn   s hould   i nclude   a ll   i ndividuals   p resent   a t   t he   l ocation    

 

Description   o f   e quipment,   b ackdrops,   s ets,   p rops   ( attach   a dditional   p ages   i f   n ecessary).   P lease   n ote   i f   a ny   o f   t he  

following   w ill   b e   i ncluded:   w eapons,   a nimals,   m inors,   n udity):      

 

 

 

 

 

Number   o f   V ehicles:  

Car,   S UV   o r   l ight   t ruck   _ ________           V ehicles   g reater   t han   a   1 0,000   l bs.   ( class   3   o r   h igher)   _ __________      

Have   y ou   p hysically   v isited   t he   r equested   a rea?    

       

 

 

                 

Y      

N  

Do   y ou   p lan   o n   a dvertising   o r   i ssuing   a   p ress   r elease   f or   t his   a ctivity?  

 

 

Y      

N        

 

When   a nswering   y es   t o   a ny   o f   t he   f ollowing   q uestions,   p rovide   a dditional   i nformation:  

Do   y ou   h ave,   o r   a re   y ou   a pplying   f or,   a   p ermit   w ith   a nother   F ederal,   S tate   o r   l ocal    

 

agency   f or   t his   a ctivity?    

 

 

 

 

 

 

 

Y          

N          

Have   y ou   h ad   p revious   p ermits   f rom   t he   N ational   P ark   S ervice?        

 

 

 

Y          

N          

Have   y ou   e ver   b een   d enied   a   p ermit   o r   h ad   a   p ermit   r evoked   b y   a   F ederal   a gency?      

Y    

N          

Have   y ou   f orfeited   a   b ond   o r   o ther   s ecurity   f or   f ilming   o n   F ederal   l ands?      

 

 

Y          

N        

Are   t here   a ny   p ending   F ederal   i nvestigations   a gainst   y ou   w hich  

 

 

 

 

 

 

involved   a   c ommercial   f ilming   a ctivity?  

 

 

 

 

 

Y          

N      

Do   y ou   a nticipate   a ny   s ecurity   c oncerns?   I f   y es,   e xplain.  

 

 

 

 

Y          

N        

 

CONTACTS:              

Person   o n   l ocation   r esponsible   f or   a dherence   t o   a ll   t erms   &   c onditions   o f   t he   p ermit:  

Name:   _ _______________________________   T itle:   _ ______________________  

Phone:   _ ___________   C ell   P hone:   _ ___________  

 

The  applicant  by  his  or  her  signature  certifies  that  all  the  information  given  is  complete  and  correct,  and  that  no  

false   o r   m isleading   i nformation   o r   f alse   s tatements   h ave   b een   g iven.  

 

 

 

Signature:     _ ___________________   P rint   N ame:   _ _____________________   D ate:   _ __________  

 

Title:   _ _________________________   Company   N ame:   _ ___________________________  

 

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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   a long   w ith   t he   a pplication   f ee   i n   t he   f orm   o f   a  credit   c ard,   c ashier’s   c heck,   m oney   o rder   o r   p ersonal  

check   m ade   p ayable   t o   N ational   P ark   S ervice   a t   t he   P ark   a ddress   f ound   o n   t he   f irst   p age   o f   t his   a pplication.  

 

If   y our   r equest   i s   a pproved,   a   p ermit   c ontaining   a pplicable   t erms   a nd   c onditions   w ill   b e   s ent   t o   y ou.   T he   p ermit  

must   be   signed   by   the   responsible   person   and   returned   to   the   park   for   final   approval   by   the   Park  

Superintendent   b efore   t he   p ermitted   a ctivity   m ay   b egin.    

 

 

NPS   F orm   1 0-­‐931   r ev   0 6/2013                                  

                                                                                                                                      O MB   C ontrol   N o.   1 024-­‐0026    

 

 

Expires   0 8-­‐31-­‐2016