TOWN OF QUARTZSITE

PARK PERMIT

APPLICANT NAME: ___________________________________________________________

NAME OF ORGANIZATION: ____________________________________________________

MAILING ADDRESS OF ORGANIZATION:

PO BOX: ____________CITY:____________________STATE:_______ZIP CODE: _________

PURPOSE OF USE:____________________________________________________________

LOCATION: __________________________________________________________________

NUMBER OF PARTICIPANTS _______________PARKING REQUEST___________________

DATE (S) OF REQUIRED USE: __________________________________________________

HOURS OF REQUIRED USE:____________________________________________________

CONTACT PERSON: _____________________

DAYTIME PHONE: (____)____-_________ CELL #:(____)______-________

Request for special liquor permit for personal use _____, if yes describe designated area:

______________________________________________________________________

NOTE: The Town of Quartzsite has first right to use of the park(s). Should a conflict occur the Town’s right will prevail. The Town will make every effort not to create an inconvenience for the applicants, but you may be requested to rearrange your schedule.

INSURANCE FOR ORGANIZATIONS: A certificate of insurance in the minimum amount of $1,000,000 naming the Town of Quartzsite as an additional insured is required, and must be attached to this application. Further, the applicant agrees to hold the Town harmless for any liability in the event of any accident or misfortune. Individuals may have their homeowners insurance endorse the event. CERTIFICATE OF INSURANCE MUST BE ADDRESSED TO: TOWN OF QUARTZSITE, PO BOX 2812, QUARTZSITE, AZ. 85346

SCHEDULE: Applications must be turned in and completed 10 working days prior to the event. You are required to attach a schedule of activities to this application. See attached sheet for Park Rules and Regulations.

Sale and or consumption of alcohol in any part of the park is prohibited except by special permit in a designated area. If you intend to sell alcohol, an ABC permit is required.

DEPOSIT REQUIRED: If electricity is needed there will be a $60.00 dollar deposit required for the use of the electric in any area of the Town Park. There will be a per/post inspection of the event to assure the area is clean. If the area is clean then $50.00 will be returned and the remaining $10.00 will the charge for the use of the electric. I have read and understand the rules and regulations. Failure to obey the rules and regulations may result in the loss of your deposit and the possible elimination of the park, by signing the park permit I accepts the rules.

______________ _________________________________________

DATE APPLICANT SIGNATURE

******************************* Town Use Only *********************************

1. Insurance Certificate attached ______ yes ______ no

1a. Expiration date of certificate: _________________

2. Schedule Attached _______yes _______no

Permit: _____ APPROVED _____ DENIED DATE: _______________________

______________________________ ______________________________

DATE POLICE CHIEF DATE PARK SUPERVISOR