Print and complete the application and send to: City Hall, 201 S. Franklin, Kirksville, Missouri 63501 * Call 660-627-1251 if you have questions or need assistance.
SPECIAL EVENT APPLICATION
City of Kirksville
Title, Purpose and Brief Description of Proposed Event ______________________________________________________________________________________________________________________
Event Name _________________________________________________________________________________________________
Contact Person _____________________________________Address___________________________________________________
Phone ______________________Fax__________________________ E-mail address_______________________________
Proposed Event Date_________________________________________________________________________________________
Requested hours of operation:________ am/pm to __________am/pm Set up & Dismantle Dates _________Time:__________
Answer “yes” or “no” to indicate if any of the following activities will be a part of your event:
____Route of event _____ Entertainment or stage locations.
____Food Concession areas. _____ Portable toilet facilities with location and number.
____Parking areas _____ Organizer’s command post.
____Cooking Areas _____ Tents, displays, and enclosures.
____Temporary or permanent structures _____ Trash containers (indicate number.)
____Will alcoholic beverages be served? _____ Do you need to have access to water?
____First aid stations or medical care. (Have you contacted the Adair County Ambulance?)
____Does the street need to be closed for the event? (Street closures require Council approval.)
____If there is to be music describe type of music, sound, or noise as well as intended hours.
____Have you contacted the Adair County Health Department for a permit?
Please provide at least 10 days prior to event:
Complete description of event, including estimated attendance. Include:
*Vendor list with name of business, name of owner, address & phone number.
*Security plan (Kirksville Police Department does not provide private security for activities).
*Food service plan meeting requirements of Adair County Health Department.
*For not-for-profit organizations, affirmation letter of 501(c)(3) status.
*Emergency plan
*Off street parking plan
*Merchandise vendor, food vendor, stage & other activities location plan
* Lighting and sound system
*Toilet facilities including disposal of sewage, trash, and refuse.
*Temporary banner or signs
*For parades, include a map of the proposed route
Insurance for events to be held on public property must furnish an insurance certificate:
*General Liability insurance for one million dollars ($1,000,000) listing the City as an additional insured
*Or, if you have no insurance coverage, an application is available through the City’s TULIP program.
The City of Kirksville reserves the right to modify or cancel the proposed special event should special conditions or and emergency exist or if the guidelines of this policy are not followed. The City of Kirksville is not responsible for Lost or Stolen Property. The City of Kirksville does not discriminate on the basis of race, color, national origin, sex, religion, age, or disability status in the provisions of services.
The Sponsor hereby agrees to hold the City of Kirksville harmless from any an all suits, claims, damages, and causes of actions of any kind arising from or relating to the proposed Special Event, including property damage and injury to persons, including death.
Applicant’s Signature and Date_______________________________________________________________________
For City Use: Investigations/Inspections Made
_______ Fire ______ Police _______Codes _________Insurance __________City Council or City Manager _________Fees Paid
__________ Approved _________ Not Approved __________ Date applicant notified of approval/non-approval
Signature ____________________________________________________________________Date ___________________________