Application for Use of Herkimer Town Park

Deposit Required of $100 and will be returned upon final inspection.

To be filled out by the applicant:

• DATE REQUESTED FOR USE
• TIME REQUESTED FOR USE
• APPLICANT'S NAME
• GROUP/ORGANIZATION REPRESENTED
• APPLICANT'S ADDRESS
• ORGANIZATION'S ADDRESS
• CITY/STATE/ZIP CODE (applicant)
• CITY/STATE/ZIP CODE (organization)
• TELEPHONE NUMBER (applicant)
• TELEPHONE NUMBER (organization)
• PURPOSE FOR REQUEST
• NUMBER OF PEOPLE EXPECTED TO ATTEND
• WILL ALCOHOL BE PRESENT: Yes / No
• APPLICANT SIGNATURE
• TOWN RESIDENT: Yes / No
• DATE

Check each park area you will need for your event

• PAVILION
• BALL FIELDS (1 OR 2 FIELDS)
• PLAYGROUND
• TENNIS COURT
• PICKLEBALL
• BASKETBALL COURT

REMEMBER, THIS IS YOUR PARK------PLEASE TAKE CARE OF IT

TO BE FILLED IN BY TOWN REPRESNTATIVE

• Insurance Certificate Required: Yes / No
• Certificate on file:

For Town Board Use ONLY

• APPROVED
• DISAPPROVED
• REASON:
• Authorized Signature
• Date

TO BE GIVEN TO THE APPLICANT

Your request to use Herkimer Town Park on: ________ has been approved by the Herkimer Town Board. We are very happy that you will be enjoying the facilities the park has to offer.