Form 125612 - Event Application For Use Of A Department-Owned Or Managed Building, Grounds Or Parking Area

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Event Application
For use of a Department-owned or managed building, grounds or parking area
(Event Sponsored by a Private, Non-profit, or Public Entity)
Approval is contingent upon receipt of this completed and signed application.
DAS NUMBER: _________________________________
DAS USE ONLY
User name and Organization name
Event / Function Name
User mailing address
Expected Number of Participants
City, State and Zip code
Contact Person Name
Email address
Phone Number
Contact Cell Phone
Government activities receive first priority for space use. Government activities are defined as by and for the conduct of
government business. Once your application is approved, please be aware that the information you provide here may be
disclosed if requested under Oregon State’s Public Records law. Please do not advertise your activity until you are issued
a permit. User's custody begins the moment the User takes possession and ends when the State regains possession.
Premises Requested:
Event Date /Time
Start Date
Time
End Date
Time
Begin
End
Event needs; support services from us:
Yes
No
Comments
Bus parking needs or alternative parking to
accommodate the participants?
Will food be sold?
Proper permits and health certificates from the
City of Salem and Marion County Health Dept. are
the responsibility of the user.
Portable restrooms. What arrangements have
been made for restrooms and drinking water?
Electricity needs. Indicate what type.
(Circuits are limited to handle 20 amps each)
Sound system and stage?
A noise variance may be obtained from the City of
Salem at 503-58-6256.
Table and chair set up?.
Security provisions? Indicate who, how many and
other information.
Do you desire the Capitol Mall Plaza “Wall of
Water” fountain on?
(Note, during windy conditions or mechanical
problems, fountains may need to be off).
Will you have a first aid and information booth?
Is General Liability Insurance Certificate attached?
Description of Event:
125612 Event Application 11-2017
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