Town of Thompson, Sullivan County, New York
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Name:
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Address:
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City state zip:
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Telephone number:
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Fax number:
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Organization:
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Address of organization:
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City state zip of organization:
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Purpose of event:
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Expected date and time of event:
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Expected duration of event:
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Number of persons expected to attend:
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There will be additional charges for attendance
in excess of stated maximum.
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Do you require exclusive use of the park: Yes
[ ] No [ ]
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If Yes, what areas will be requested to be reserved:
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Will a fee be charged to attend:
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Yes [ ]
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No [ ]
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(Fee may be charged only for special event)
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Will alcohol be served:
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Yes [ ]
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No [ ]
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Will there be a charge for alcohol:
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Yes [ ]
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No [ ]
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If yes to questions concerning sale or use of
alcohol, attach certificate of insurance.
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Minimum coverage _________________________ issued
by ___ rated (AM Best) New York State authorized insurance company.
Alcohol is prohibited unless authorized by permit.
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Attach certificate of insurance for general
liability with policy limits of ____________________________________
issued by ___ rated (AM Best) New York State authorized insurance
company.
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Do you or your organization owe the Town of
Thompson any fees and charges for prior events: Yes [ ]
No [ ]
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If Yes, describe the circumstances of the obligation.
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Attach check payable to Town of Thompson for
the amount claimed by the Town which is unpaid.
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Fees and Charges
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Use fee
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$
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Cleanup deposit
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$
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Additional cleanup
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$
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Other charges
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$
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Total
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$
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I and my organization agree to pay all additional
fees and charges for the use and cleanup of the park. I and my organization
agree to indemnify and hold harmless the Town of Thompson from any
and all liability arising as a result of the use of the Town park
pursuant to the permit issued by the Town. We shall be liable for
damages, interest, court costs, legal fees and any other charge incurred
by the Town. The undersigned certifies that he or she is duly authorized
to act for and on behalf of the organization listed.
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Date:
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Organization name:
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By:
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For official use only
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Fees paid
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$
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Permit granted: __________ 20__
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Cleanup
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$
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Limitations:
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Additional CU
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$
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Other information:
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Other fee
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$
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Past due
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$
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By: Park Superintendent:
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s/
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