(NFS Form 10.930)                                                                                                                                                    (0MB No. 1024-4026)

(NEW 10/00)                                                                                                                                                               (Expires 12/31/2006)

NATIONAL PARK SERVICE

Hot Springs National Park

P.O. Box 1860

Hot Springs, Arkansas 71902

Application for Special Use Permit

Please supply the information requested below. Attach additional sheets, if necessary, to provide required information. Allow at least four (4) business days for processing. A non-refundable processing fee will be required to accompany this application unless the requested use is an exercise of a First Amendment right. You will be notified of the disposition of the application and the necessary steps to secure your final permit. (Note: there may be additional fees charged, and you may be required to provide proof of liability insurance.)

Applicant Name:                                                    Organization Name:                                              

Social Security:                                                       Tax ID:                                                                  

Street/Address:                                                                                                                                  

City/State/Zip Code:                                               City/State/Zip Code:                                             

Telephone #:                                                           Telephone #:                                                         

Cell phone #:                                                           Cell phone #:                                                        

Fax #:                                                                      Fax phone #:                                                        

Description of Proposed Activity (attach diagram):

_______________________________________________________________________________              _______________________________________________________________________________

_______________________________________________________________________________

Requested Location: _______________________________________________________________ 

Date (s):          ____________________________________________________________________

Maximum Number of Participants: __________________________(Please provide best estimate)

Maximum Number of Vehicles: ___________________________________ (attach parking plan)

Support Equipment (list all equipment)_________________________________________________ 

______________________________________________________________________________

Support Personnel (contractors, etc. including addresses and telephones) _______________________

______________________________________________________________________________

Individual in charge of the event on-site (include address, telephone and cell numbers): _____________ ______________________________________________________________________________

Is this an exercise of First Amendment Rights?                                  Y        N

Are you familiar with/have you visited the requested area                  Y         N    

Do you plan to advertise or issue a press release?                             Y        N

Will you distribute printed material?                                                  Y        N

Is there any reason to believe there will be attempts to disrupt,          

protest or prevent your event? (if yes explain on separate sheet)        Y        N

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: ________________________________Date: ____________________________

Information provided will be used to determine whether a permit will be issued. Completed application must be accompanied by an application fee in the form of a cashiers check or money order in the amount of $___.00 made payable to National Park Service. Application and administrative charges are non- refundable. This completed application should be mailed to Park address information, attention: Permit Coordinator.

Note that this is an application only, and does not serve as permission to conduct a filming project or any other use of the park. If your request is approved, a permit containing applicable conditions and regulations will be sent to the person designated on the application. The permit must be signed and returned to the park prior to the event.

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The above application form is provided with the understanding that parks will insert appropriate park names and addresses and the amount of the application fee as desired.

Paperwork Reduction Act Statement: This information is being collected to allow the park manager to make a value judgment on whether or not to allow the requested use. All the applicable parts of the form must be completed. A Federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid 0MB control number.

Estimated Burden Statement: Public reporting burden for this form is estimated to average 30 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 National Park Service, Special Park Uses Program Manager, 1849 C Street NW (2460), Washington, D.C. 20240

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