EXHIBIT 4 VILLAGE FORMS, PERMITS AND APPLICATIONS.

THE VILLAGE OF BLUFFTON
APPLICATION FOR SPECIAL EVENTS

APPLICANT: ____________________________   EVENT: ____________________________

Address 1 ________________________________   Address 1 ___________________________

Address 2 ________________________________   Address 2 ___________________________

Phone No: _______________________________   Phone No: ___________________________

Dates of Event: __________________________________________________________________

Description of Event: _____________________________________________________________

________________________________________________________________________________

List the Services, Vendors, Contractors, Etc. Involved:

Vendors:    ________________________________   Type _____________________________

       _________________________________   Type _____________________________

       _________________________________   Type _____________________________

       _________________________________   Type _____________________________

       _________________________________   Type _____________________________

Safety Services Provided: (Applicant must provide a map of plans and any other information required as necessary)

Traffic Control:     Local Police - Number needed ____   Other Service - Number needed _______

Security:       Local Police - Number needed ____   Other Service - Number needed _______

EMS Services:    Local Service [ ]   Other Service [ ]

Fire Dept:       Local Service [ ]   Other Service [ ]

Number of Officers required to cover security will be determined and required on a case by case basis.

Alcohol is Served: Yes _______ No _______ Applicant is responsible for obtaining the proper alcohol permit from the Division of Liquor Control prior to the event.

Insurer: (Village listed as Additional Insured) ____________________________________________

                        (Attach Certificate of insurance)

I understand that the granting of this permit for the special event creates no agreement or guarantee, express or implied, to any person or entity for any liability whatsoever connected with this special event. Any liability is the sole responsibility of the person or organization responsible for the special event. By signing this application, I acknowledge that all statements made herein are true and correct and that I have the authority to bind the organization that I represent.

Applicants Signature _______________________   Date: _______________________________

APPROVED:

Mayor ___________________________________   Date: ________________________________

   Attach additional sheets as necessary

(Ord. 17-02, passed - -2002; Ord. 28-02, passed 11-25-2002)