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2. REASON FOR PERMIT*
   -- Select One --Admission ChargedContribution CollectedOpen to the General Public
4. NAME*
5. ADDRESS*
7. PHONE NUMBERS*
8. EMAIL*
10. EVENT NAME*
11. EVENT LOCATION NAME AND ADDRESS*
13. EVENT DATE*
14. EVENT TIME*
15. NO. OF EXPECTED ATTENDEES:*
16. NO. OF EXPECTED TICKETS SOLD:*
18. IS THE APPLICANT THE PROPERTY OWNER?*

    1. Yes
    2. No
19. IF “NO,” PLEASE ATTACH A NOTARIZED LETTER FROM THE PROPERTY OWNER AUTHORIZING USE OF THE PROPERTY FOR THE EVENT.*
21. WILL ALCOHOL BE SOLD OR CONSUMED*

    1. Yes
    2. No
22. TYPES OF ALCOHOL*
23. IF “YES,” PLEASE ATTACH A COPY OF THE VIRGINIA ALCOHOLIC BEVERAGE CONTROL LICENSE FOR THIS EVENT. IF BEING SOLD, A DINWIDDIE COUNTY BANQUET LICENSE IS ALSO REQUIRED.*
25. IS THERE A PROMOTER FOR THIS EVENT?*

    1. Yes
    2. No
26. PROMOTER NAME*
28. PROMOTER ADDRESS*
30. PROMTER PHONE NUMBER*
31. PROMTER EMAIL*
32. PERFORMERS (IF ANY)*
34. ELECTRICAL DEVICE INSTALLATION

    1. YES
    2. NO
35. OUTDOOR LIGHTING

    1. YES
    2. NO
36. BLEACHERS

    1. YES
    2. NO
37. TENTS

    1. YES
    2. NO
39. TENT QUANTITY
40. TENT SIZE
41. TENT FLAPS

    1. UP
    2. DOWN
43. AMUSEMENT RIDES

    1. YES
    2. NO
44. AMUSEMENT RIDE DESCRIPTION
45. BUSINESS LICENSE:

    1. YES
    2. NO
47. WHO WILL RECEIVE PROCEEDS?
49. IF NONPROFIT ORANIZATION, LIST EIN:
50. Ticket Prices
52. IF EVENT IS HELD AT A PARK; THE PARK RECIEVES: FLATE FEE OF $_______
53. IF EVENT IS HELD AT A PARK; THE PARK RECIEVES: AMOUNT FROM TICKETS SALES OF $ _______PER TICKET.
54. IF EVENT IS HELD AT A PARK; THE PARK RECIEVES: PERCENTAGE AMOUNT FROM TICKET SALES OF _______%
56. TRANSIENT OCCUPANY TAX: WILL OVERNIGHT STAYS BE ALLOWED?

    1. YES
    2. NO
57. MEALS TAX:
    -- Select One --BlankFOOD TO BE SOLD (ATTACH PRICE LIST)PROVIDED FREE OF CHARGE
58. VENDORS
    -- Select One --BlankYESNO
60. IF “YES,” PLEASE ATTACH A LIST OF ALL VENDORS INCLUDING THEIR NAME, ADDRESS, PHONE NUMBER, AND EMAIL.
62. PLAN FOR GARBAGE, TRASH, AND SEWAGE DISPOSAL?
64. COMPLETE ATTACHED HEALTH DEPARTMENT FORM IF FOOD IS BEING SERVED OR COOKED.
66. IF IT IS DEEMED NECESSARY TO HAVE ON-SITE MEDICAL OR FIRE PROTECTION, PLEASE CONTACT FIRE AND EMS AT 804-469-4588.
68. ACCORDING TO THE COUNTY’S SECURITY POLICY

    1. DEPUTIES/SECURITY OFFICERS ARE REQUIRED
    2. I REQUEST ____ DEPUTIES AT $40/HOUR
    3. I WILL PROVIDE MY OWN SECURITY OFFICERS
    4. IT IS UNDERSTOOD THAT ALL SECURITY OFFICERS MUST POSSESS A DCJS CERTIFICATION CARD AND PRESENT IT UPON REQUEST BY LAW ENFORCEMENT.
69. # OF DEPUTIES
71. By signing below, I pledge and certify the following:
    1. I hereby certify that the information on this form and the documents provided for support are accurate, true and correct to the best of my knowledge and belief.
    2. I pledge to hold the special event described on this application in accordance with all applicable federal, state, and local laws and regulations.
    3. I authorize the county administrator; his lawful agents, including but not limited to those officials approving plans and providing certifications as required by the Dinwiddie County Code, and duly constituted law-enforcement officers to go upon the property at any time for the purpose of determining compliance with all applicable federal, state, and local laws and regulations.
73. VENDOR LIST (INCLUDE NAME, ADDRESS, PHONE NUMBER, EMAIL ADDRESS)
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75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit

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