SPECIAL ACTIVITY

PERMIT REQUEST

APPLICANT MUST PROVIDE ALL REQUESTED INFORMATION AT LEAST TWO WEEKS PRIOR TO THE EVENT

1. APPLICANT: Name, address and daytime phone number of the individual, group or organization. Also give name, address and phone number of person who will coordinate with the Corps during the event, be responsible for compliance with all permit terms and conditions, and assure clean-up after the event.

ORGANIZATION______

(Include Name, Address, City, State & ZIP)

COORDINATOR______

(Include Name, Address, City, State & ZIP)

PHONE Day ______Evening ______Cell ______

ALTERNATE COORDINATOR______

(Name, Address)

PHONE Day ______Evening ______Cell ______

2. PROPOSED ACTIVITY: Describe the proposed activity and who would conduct and participate. Include the date, time and specific location.

______

Location______Date______Time______

3. PARTICIPANTS EXPECTED______

ADDITIONAL PEOPLE: Spectators______Visitors______

4. Will fees or entrance donations of any type to be collected from the public or participants? If “YES”, cite the amount and purpose for which they would be assessed (entry fee, spectator fee). What is the expected gross revenue? For what purpose will the collected funds be used?

5. Will the event involve vendors? If yes, list each individually.

Page 1

6. How will access to and from the event area be controlled and non-participating vehicle and/or boat traffic be directed around or through the event area?

7. Are the existing sanitary facilities adequate to handle expected crowds? If no, what measures will you take to provide necessary facilities?

8. Will first-aid stations, ambulances or other safety measures be required? If yes, what measures will you take to provide needed services and equipment?

9. Will buoys, temporary course markers, or lake traffic control measures be required? If yes, list requirements.

10. Are additional permits from other governmental agencies required? If yes, list agencies and type of permits.

11. Will additional security measures be required for crowd or traffic control? If yes, what measures will you take to ensure public safety?

SIGNATURE______DATE______

The Privacy Act of 1974 requires that each individual asked to furnish personal information be advised of the following:

Authority: 5 P.L. 93-579

Purpose: To provide a contact in connection with permit activities.

Routine Uses: Permit is issued under direction of the Fort Worth District Corps of Engineers. The name and address of those obtained are not reported, but are kept on file at the project office to provide a point of contact in case of emergency. This information is not maintained alphabetically or by other personal identifier. Disclosure of information is voluntary. Failure to provide the requested information will preclude issuance of permit.

Page 2