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Special Event Application (Municipal Entities)

  1. Is this a new event?*

  2. Sponsoring Organization

  3. 501(c) Non-Profit (Check if NFP)

  4. Organization's Event Coordinator Contact

  5. Event Details

  6. Yearly Event*

  7. Will portable toilets be used?*

  8. Please check all applicable

    Barricades - Note: barricades are NOT provided by the City and are the responsibility of the sponsoring organization. Upon request, the City can provide the event coordinator with a list of companies that rent barricades.

  9. $120 for first 20, Add $70 for each additional 20 barrels.

  10. Does the organization wish to make a funding request to the Special Events Committee?*

  11. INSURANCE – a certificate of insurance must be provided and include the following under the certificate’s Description of Operations section:

    • The event name, date(s) and location; and
    • The following language: City of Moline is an Additional Insured on the Commercial General Liability, Auto Liability and Excess Liability when required by written contract or agreement regarding activities by or on behalf of the Named Insured. This insurance is primary insurance and any other insurance maintained by the Additional Insured shall be excess only and non-contributing with this insurance. A waiver of subrogation applies to the Commercial General Liability, Auto Liability, Excess Liability and Workers’ Compensation/Employers Liability in favor of the Additional Insured. A copy of the (30) days notification of cancellation endorsement needs to be included with the Certificate of Insurance naming the City of Moline.
    • If liquor is being sold or dispensed, $1,00,000 liquor liability coverage must be included.

  12. Submission of Documents

    • For this application to proceed, all applicable fees must be paid online or at the City of Moline Accounts & Finance Department located at 1630 8th Avenue, Moline, IL 61265.

  13. All licenses and permits required herein are separate requirements. Depending upon the nature of the event, it is possible that more than one license or permit will be required and the undersigned acknowledges and understands it is his/her obligation to secure ALL necessary licenses and/or permits. The undersigned is authorized to act on behalf of the organization, and agrees to the necessary costs, insurance requirements, and other guidelines identified in the Special Event Application or any document, license, or permit referenced herein; and further agrees to provide the City Clerk with all required necessary documents, including the executed cost estimated memorandum, which will be forwarded to the Event Coordinator shortly after this initial application is completed.

  14. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  15. Leave This Blank:

  16. This field is not part of the form submission.