Designated Limited Public Forum Application Form printable pdf download

Office Use Only

Parks & Recreation Department

Taken by:__________Date:______

3179 Livernois, Troy, 48083

Location:_____________________

248.524.3484

Deposit Paid:______________

DESIGNATED LIMITED PUBLIC FORUM APPLICATION

Name of Individual/

Company/Group:________________________________________________________________________________

Address:______________________________________________________________________________________

Date of Function:_________________ Number of Users:________Time of Use*: Begin:__________End:__________

Location (attached schematic shows available sites):___________________________________________________

Please read these carefully before completing your application. The undersigned hereby verifies that he/she:

1. Has the authority to sign this application for the above named organization, group or company.

2. Has read the rules and regulations on the back of this form and agree to abide by all rules stated therein.

3. Will perform the necessary clean up of the area following its use.

4. Understands the approval of this application may include non-content based additional requirements and/or

limitations based on time, place, and manner criteria.

5. Agrees to stay within the boundaries of the reserved area and to limit gathering to this area.

6. Has read and understand that permits are subject to all policies, rules and regulations as listed on the back of this

form.

7. Understands that failure to comply with all policies, rules and regulations herein stated or falsification of any

information called for in this application will be grounds for denial of this or any future permits.

8. Understands that the City does not intend to provide any service associated with the forum. In cases where the

forum requires City staff to perform work that would not be required if the Applicant’s requested use did not take

place, the applicant will be charged the costs associated with the work. The labor performed by staff will be at the

discretion of the City Manager and/or designee and the applicant may not be notified of the requirement for

services prior to the service being performed. Should there be any costs incurred by the City, the applicant will be

invoiced for additional costs within 30 days of the Applicant’s use of the forum.

Please print/type name of contact person: ____________________________________________________________

Address:______________________________City/Zip:_______________________Phone:_____________________

Name of alternate contact person:__________________________________________________________________

Address:______________________________City/Zip:________________________Phone:____________________

The Applicant agrees to defend, indemnify and hold the City of Troy, its officers, officials, agents and employees,

harmless from and against all claims arising by reason of injury or death of any person or damage to property arising

out of or incidental to its use, except to the extent caused by the gross negligence or willful misconduct of the City, its

agents and employees. The City shall provide the Applicant with notice of any claim which the City believes is covered

by this agreement, and the Applicant shall timely appear in and defend all suits brought upon such claim and shall pay

all incident costs and expenses, but the City shall have the right, at its option, to participate in the defense of any suit

without relieving the Applicant of any of its obligations.

I hereby affirm that the information I provided on this Designated Limited Public Forum Application form is

true to the best of my knowledge, information and belief. I further agree on behalf of myself, my

organization, and any others working with me or participating with me, that we will comply with the City’s

rules, the terms of the written confirmation of approval and all other City requirements, ordinances and

other laws that apply to this use. Any violation thereof may result in the City’s retention of the entire

deposit, and does not preclude any other applicable action/s for the violation/s.

_____________

____________________________

_______________________________________

Date

Applicant’s Name (please print)

Applicant’s Signature

Confirmation of Approval

Approved by:___________________________Date approved:______________________________

Location: Circle one

Town Center/Livernois Greenspace

Reflective Head

Parking lot N. of Community Center

Veterans Plaza

Designated Limited Public Forum Application Form

Related Articles

Related forms

Related Categories