North Cascades National Park 1/28/2020

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. Yes 0 No ® If"Yes",please provide the following information. Attach additional pages,if necessary. 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 Application/Administrative Fee as outlined in Attachment C. 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. ¢lr¢ c J . ive,ctt a tresis By my signature,441arabooPtest that all my statements and answers on this form and any attachments are true,complete,and accurate to the best of my kn e. I k-A0 6 signature/ /til epic_ Date Printed Name Title r(/I Office of the City Attorney oy o2 APPROVED AS TO FORM Ctrs<< `r kt� Q NOTICES David C.Hall,City Attorney Frew.. 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. NPS Form 10-550(Rev.11/2016) �1^� ST: OMB Control No.1024-0268 National Park Service • Expiration Date: 11/15/2019 .4/1../ _ City lerk