Author: Grace Bibber

Application of Use of Town Public Land and Parks
185 Portland Road, Buxton, ME 04093

Name & Address of Organization:

Non-Profit Organization Federal I.D. #

Private/Commercial Organization

Insured: ___ YES _____ No

Insurance Liability Certificate Info: ____________________________________

Facilities Desired:

Date or Dates Desired (list each event separately. If application is for a weekly function, please state the beginning and ending dates.)

Purpose of use:

Number of Persons Expected:

Type of Activities to be Conducted. (Please be complete & specific as each activity requires separate approval)

Time activity will start:

Time activity will end:

Will you be charging admission? Yes _____ No ______ If yes, proceeds will go to:_________________________
_______________________________________________________________________________________

Any person who submits a application of use of town public land and parks shall observe all rules, regulations and ordinances adopted by the Town of Buxton. Open fires are not permitted on Town Property. The person who submits the application of use, is liable for any loss, damage or injury sustained by any person or property whatsoever by reason of negligence by anyone who is taking part of the activity which the application is filed under. The Town of Buxton and any of its agents, servants and employees harmless from any and all losses caused by the person filing the application or any person engage in activity being sponsored under this application.

Name of Applicant: _______________________________ Date:______________________
Address: __________________________Home Phone: _________________ Work Phone:____________
Tile of Applicant in organization:___________________________________________________________
Signature of Applicatant:____________________________________________________________

OFFICAL USE ONLY:
APPROVED

Approved By:

Town Offical

DENIED (reason of denial) :___________________

Approval Date: ___________________