ML13083A213

NRC Form 590 - Application/Permit or Use of the Two White Flint North (TWFN) Auditorium

ML13083A213
Person / Time
Issue date:	08/31/2016
From:	NRC/OCIO/GEMSD/IMSB
To:
References
Download: ML13083A213 (2)

Text

NRC FORM 590 U.S. NUCLEAR REGULATORY COMMISSION (08-2016)

APPLICATION/PERMIT FOR USE OF THE TWO WHITE FLINT NORTH (TWFN) AUDITORIUM Because fewer than ten respondents submit this form annually, this form is not a collection of information as defined by the Paperwork Reduction Act of 1995 and 5 CFR Part 1320.3(c). No Office of Management and Budget clearance is required.

INSTRUCTIONS: Please submit with this application a copy, sample, or description of any material or item(s) proposed for distribution or display. Complete the check list of service needs for public-use space on the reverse of this form. Failure to complete this form will result in denial of a permit.

IMPORTANT: If the applicant proposes to represent an organization, a letter or other documentation that the applicant has authority to represent that organization must be submitted with this form.

From (MM/DD/YYYY) Hour AM or PM To (MM/DD/YYYY) Hour AM or PM

1. Proposed Date(s) Select Select Select Select

2. Name of Applicant (First, Middle Initial, Last) Business Telephone Number Business Address (Street, Suite/Apt. No., City, State and Zip Code)

3. Name of Person or Organization Sponsoring, Promoting, or Conducting the Proposed Activity Business Telephone Number Business Address (Street, Suite/Apt. No., City, State and Zip Code)

4. Name of Person(s) Who Will Supervise/Be Responsible for the Proposed Activity Business Telephone Number Business Address (Street, Suite/Apt. No., City, State and Zip Code)

5. Description of Proposed Activity

6. Certification AN APPLICANT PROPOSING TO ENGAGE IN THE SOLICITATION OF FUNDS MUST CHECK ONE OF THE FOLLOWING STATEMENTS:

I CERTIFY THAT:

I represent and will be soliciting funds for the sole benefit of a religion or religious group.

My organization has received an official Internal Revenue Service (IRS) ruling or letter of determination stating that the organization or its parent organization qualifies for tax-exempt status under 26 U.S.C. 501(c)(3),(c)(4), or (c)(5).

My organization has applied to the IRS for a determination of tax-exempt status under 26 U.S.C. 501(c)(3),(c)(4), or (c)(5) and that the IRS has not yet issued a final administrative ruling or determination of such status.

I certify that I am authorized to sign this application on behalf of the named organization. I have read and fully comprehend all fees, rules, and regulations contained in the policies and procedures associated with the use of the Two White Flint North Auditorium. I fully accept liability for any damages that may occur during the scheduled use or any additional charges that may result from the designated use of the auditorium.

Signature - Applicant Date NRC FORM 590 (08-2016) Page 1 of 2

NRC FORM 590 U.S. NUCLEAR REGULATORY COMMISSION (08-2016)

APPLICATION/PERMIT FOR USE OF THE TWO WHITE FLINT NORTH (TWFN)

AUDITORIUM (Continued)

CHECK LIST OF SERVICE NEEDS FOR PUBLIC-USE SPACE AUDITORIUM (Check items needed) CATERING KITCHEN MICROPHONE Will Food or Drink be Served During Program Hours? YES NO PODIUM It is the user's responsibility to ensure that the kitchen is DAIS CONFIGURATION clean and in order before leaving the premises.

NRC USE ONLY SCHEDULE OF HOURLY COSTS FOR SERVICES All programs are after NRC normal hours of operation. The following is a schedule of hourly costs for services.

FEE SCHEDULE FEE FROM AM PM TO AM PM COST PER HOUR $ 222 Select Select Select Select Select Select Select Select TOTAL ADMINISTRATIVE REVIEW APPROVED DISAPPROVED If Disapproved, Reason for Disapproval Reviewing Official (Typed or Printed Name and Title)

Signature of Reviewing Official Date (MM/DD/YYYY)

SECURITY REVIEW APPROVED DISAPPROVED Reviewing Official (Typed or Printed Name and Title)

Signature of Reviewing Official Date (MM/DD/YYYY)

PERMIT FOR USE OF THE TWO WHITE FLINT NORTH AUDITORIUM BASED UPON ADMINISTRATIVE AND SECURITY REVIEWS, THIS APPLICATION IS: APPROVED DISAPPROVED Reviewing Official (Typed or Printed Name and Title)

Signature of Reviewing Official Date (MM/DD/YYYY)

NRC FORM 590 (08-2016) Page 2 of 2