Special Events Application

• PERMIT NUMBER

APPLICANT INFORMATION

• Applicant: NAME / E-MAIL ADDRESS
• ADDRESS / ZIP CODE / TELEPHONE NUMBER / FAX NUMBER
• Date of Application
• Sponsor / TELEPHONE NUMBER
• Organization (if applicable)
• Names, Addresses, and Daytime Telephone Numbers of Two Organization Officers Besides Applicant (if applicable): 1. / 2.

EVENT INFORMATION

• Have you held this event before? Yes / No (circle one)
• If yes, provide event name, date, and permit #:
• Type of Event
• Date of Event
• Name of Park
• Location in Park (be specific)
• (If appropriate) Start Location
• Finish Location
• Route through Park
• Number of Participants
• Number of Spectators
• Set-Up Begins
• Clean-Up Ends
• Time Event Begins
• Time Event Ends
• * Will participants or spectators be charged? YES / NO. If so, how much?
• * Will there be vendors at the event? YES / NO. If so, what is the vendor permit fee?
• * Will there be merchandise available for sale YES / NO. If so, provide a list of items and prices.
• Describe in detail activities planned. List all items to be distributed. (Sale or distribution of food, products, promotional material, celebrities, speeches, ceremonies, equipment to be used, etc.) - MUST BE COMPLETED
• Will the event be advertised? YES / NO If so, describe advertising plan including dates and media outlets.
• Will any pamphlets, handbills, or advertising matter of any kind be distributed at the event?
• Have you made any provision for on-site medical services? YES / NO
• Have you made any provision for on-site security? YES / NO
• Do you have insurance? YES / NO. If so, with whom?
• Do you plan to have amplified sound at event YES / NO
  A permit from the local police precinct is required for all amplified sound.

As the applicant, I hereby certify that the information I have provided on the form is complete and accurate to the best of my knowledge. I agree to abide by the terms set forth in this application,

• SIGNATURE OF APPLICANT

THIS FORM IS NOT A PERMIT
THERE IS A $25 NON-REFUNDABLE ADMINISTRATIVE PROCESSING FEE
CHECKS OR MONEY ORDERS SHALL BE PAYABLE TO:
Town of Herkimer