| City of Bethlehem
Traffic Bureau Activity Permit |
1 Date Requested | ___ Comm ___File
___Mayor
___Trf ___PubWks ___Parks ___Plt ___EMS ___Fire |
|
| 2 Contact Person: | 3
Home Address:
|
||
| 4 Phone
# Residence:
Phone # Employer: |
|||
| 5 Name of Organization: | 6 Organization Address: | ||
| 7 Phone #: | |||
| 8 Organization is:
__ Profit __Nonprofit
|
9 Insurance Carrier:
* Note: Not required for Neighborhood Block Party |
||
| 10 Event Location:
|
|||
| 11 Date of Event: | Alternative Date:
|
12 Time(s) of Event: | 13 Purpose of Event: |
| 14 Items for Sale:
___ Yes ___No |
15 Number of Participants: | 16 Type of Event: ___Block Party
___Parade ___Concert ___Other______________ |
|
| 17 Remarks:
* If other City Services are needed – Please contact Parks & Public Property at 610-865-7079 |
|||
| 18 I hereby agree
that all information on this form is correct and accurate. Any error, misstatement
or misrepresentation with or without intention can result in revocation
of this registration.
I agree that the City shall be free from all claims, demands and actions that occur with this activity. Registration does not evidence the City’s support or opposition to the activity. ___________________ ________
|
Bureau Approval:
Date
_____________________________ _________________ Bureau Denial: Date _____________________________ _________________ Reason: |
||