Chapin Community Park

Application for Permit

Name of responsible person or organization ____________________________________

Address of person or organization ____________________________________________

Contact telephone number __________________________________________________

Date activity is to be conducted ______________________________________________

Statement briefly describing proposed activity___________________________________

________________________________________________________________________

________________________________________________________________________

Hour when activity will start and terminate _____________________________________

Estimate of anticipated attendance ____________________________________________

___________________________________________ ________________________

Signature of Applicant Date

*Per ordinance ___________, after due considering of the information contained in this permit has been filed, the President shall determine whether the application is satisfactory.

Approved or Denied by the President of the Village of Chapin

This ________ day of __________________________, 2009

___________________________________________

Village President