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2. Is this a new event?*

   1. Yes

   1. No
4. Name of Event*
6. Type of Event*
8. Sponsoring Organization
10. Name*
11. 501(c) Non-Profit (Check if NFP)
13. Address*
14. Telephone*
16. City/State*
18. Organization's Event Coordinator Contact
20. Name*
22. Cell Phone*
23. Email Address*
25. Upload Drivers License*
29. Event Details
31. Set-up Date & Time*
    Set-up Date & Time

    Set-up Date & Time
32. Clean up Date & Time*
    Clean up Date & Time

    Clean up Date & Time
34. Event Start Date & Time*
    Event Start Date & Time

    Event Start Date & Time
35. Event End Date & Time*
    Event End Date & Time

    Event End Date & Time
37. Location Description*
39. Complete Location (map must be attached)
41. Estimated number of persons attending*
42. Yearly Event*

    1. Yes

    1. No
44. Will portable toilets be used?*

    1. Yes

    1. No
45. If yes, Name of vendor.
47. Please check all applicable

    1. Bounce House (Special insurance requirements)
    2. Will City-Owned Park property (Parks & Recreation Special use permit required) be used?
    3. Will you use amplified sound?
    4. Water Barrels to be filled by Water Dept.

    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.
49. Number of Water Barrels requested
    $120 for first 20, Add $70 for each additional 20 barrels.
50. Date for Water Barrels to be filled
    Date for Water Barrels to be filled
52. Certificate of Insurance
54. Does the organization wish to make a funding request to the Special Events Committee?*

    1. Yes

    1. No
56. If so, how much are you requesting?
58. How will the funds be used?
60. Upload a simple event budget
62. Plan for event security*
64. Plan for sanitation facilities and clean-up*
66. Expectation/Plan for emergency medical needs*
68. Event fire suppression plan*
70. Notes
72. 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.
76. 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.
78. 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.
80. 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.

    1. I agree.
82. Electronic Signature*
Leave This Blank:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit

* indicates a required field