CERTIFICATION BY APPLICANT: I certify that all information contained in this application is true and correct. Any falsehoods or misrepresentations will constitute grounds for immediate revocation of permit. I certify that I have reviewed The City of Eustis code article IV, section 18 (can be viewed at www.municode.com) and I agree to comply with all applicable provisions of the code. I understand the event may be cancelled by the Chief of Police or his/her designee should any conditions/stipulations of the permit or city ordinance or state statute be violated. I certify that I am authorized by the organization named herein to act as its agent for the herein described activity.
I, the undersigned, will indemnify, defend and hold harmless, the City of Eustis, its agents, employees, officers and any and all other associates, from and against any and all actions, in law or in equity, from liability or claims for damages, demands or judgments to any person or property which may result now or in the future from the conduct of this event.
The undersigned has read and voluntarily signed the release and waiver of liability and Indemnity Agreement, and further agrees that no oral representations, statements, or inducements apart from the foregoing written agreement have been made.
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Date:
Printed Name: ___
ADDITIONAL COMMENTS:___
□ Approved with Conditions
□ Approved
□ Denied
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Received by: _____ Date: _____
Signature: ___
Fees Paid: Fees Due:
Fees Paid:
Title: ___
Date Issued: ___
Date: ___ Fees Due: ___