Nps Form 10-930s - Application For Special Use Permit (Short Form) - National Park Service - U.s. Department Of The Interior

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NPS Form 10-930s (Rev. 07/2016)
OMB Control No. 1024-0026
National Park Service
Expiration Date 01/31/2020
APPLICATION FOR SPECIAL USE PERMIT
SHORT FORM
Southeast Arizona Group of National Park Sites
Chiricahua National Monument | Coronado National Memorial | Fort Bowie National Historic Site
12856 E Rhyolite Creek Rd
Willcox, AZ 85643
Attn: Dean Portman, (520) 824-3560 x9206
Please supply the information requested below. Attach additional sheets, if necessary, to provide required information. A
nonrefundable processing fee of $100 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 an additional insured.
Applicant Name
Telephone Number
Organization
Cell Phone Number
Social Security Number or Tax ID number
Fax Number
Email Address
Street Address
City
State
Zip Code
Country
Proposed Activity
Preferred Date
Preferred Location
Preferred Time
Alternate Date(s)*
Alternate Location(s)*
Alternate Time(s)*
* Alternatives will be considered if first choice is not available.
Maximum Number of Participants
Maximum Number of Vehicles
List of Equipment
Individual in charge of activity onsite who is authorized to make decisions related to
Cell Phone Number
the permitted activity:
Have you visited the requested area?
Is this an exercise of a First Amendment rights?
Yes
No
Yes
No
RECORDS RETENTION: TEMPORARY. Destroy/delete 3 years after closure. (NPS Records Schedule, Resource Management
Page 1 of 3
and Lands (Item 1D) (N1-79-08-1))

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