Special Event Application

2. Event Name*
3. Sponsoring Organization*
5. Are you a nonprofit organization? *

   1. Yes
   2. No
6. 501(c)3 Verification
10. Applicant Name*
11. Email Address*
13. Address*
15. City*
16. State*
17. Zip Code*
19. Phone Number*
23. Are you making this request on the behalf of the Event Organizer?

    1. Yes, I'm not the Event Organizer
    2. No, I'm the Event Organizer
25. Event Organizer Name
26. Event Organizer's Email Address
28. Event Organizer's Phone Number
30. Name of On-Site Contact *
31. On-Site Contact Phone Number*
35. Requested Facility Location*
    -- Select One --Abbey Nature PreserveHampstead AnnexHampstead Kiwanis ParkHolly Shelter Shooting RangeMillers Pond ParkPender County Courthouse SquarePender Memorial ParkPenderlea Community Park
37. Hampstead Annex

    1. Auditorium
    2. Meeting Room - 1st Floor
    3. Parking Lot
38. Hampstead Kiwanis Park

    1. Large Picnic Shelter
    2. Small Picnic Shelter
    3. Stage
    4. Sand Volleyball Courts
    5. Tennis Courts
    6. Basketball Courts
    7. Pickleball Courts
    8. Phase IV Picnic Shelter
40. Millers Pond Park

    1. Picnic Shelter
    2. Dock - Overview
    3. Kayak Launch
41. Pender Memorial Park

    1. Picnic Shelter
    2. Parking Lot - Paved
    3. Parking Lot - Gravel
43. Penderlea Community Park

    1. Auditorium
    2. Classrooms
    3. Gym
44. Pender County Courthouse Square

    1. Gazebo
    2. S Wright Street Side
    3. E Wilmington Street Side
    4. Walker Street Side
    5. E Fremont Street
    6. Entire Square
46. Will this event require street closures?

    1. Yes
    2. No
47. If yes, please contact The Town of Burgaw
    Town of Burgaw Special Event Permits
49. Requested Event Date*
    Requested Event Date Start Date

    Requested Event Date Start Time

    —

    Requested Event Date End Date

    Requested Event Date End Time

    Please use this space to tell us how long the actual event is planned for. The next 2 spaces will be for set-up and break-down times.

50. Set-Up Time*
    Set-Up Time Start Time

    —

    Set-Up Time End Time

    Please use this space to let us know what time set-up will begin and end.

51. Break-Down Time*
    Break-Down Time Start Time

    —

    Break-Down Time End Time

    Please use this space to let us know what time break-down will begin and end.

53. Set-Up Date and Time (if different than event day)
    Set-Up Date and Time (if different than event day) Start Date

    Set-Up Date and Time (if different than event day) Start Time

    —

    Set-Up Date and Time (if different than event day) End Date

    Set-Up Date and Time (if different than event day) End Time
54. Break-Down Date and Time (If different than event day)
    Break-Down Date and Time (If different than event day) Start Date

    Break-Down Date and Time (If different than event day) Start Time

    —

    Break-Down Date and Time (If different than event day) End Date

    Break-Down Date and Time (If different than event day) End Time
56. Additional Date
    Additional Date Start Date

    Additional Date Start Time

    —

    Additional Date End Date

    Additional Date End Time
57. Comments for Additional Date

    *Rain Date / Multiple Day Event / Etc.

61. Estimated Attendance*
    -- Select One --0-100100-200200-300300-400400-500500-1,0001,000-5,000
62. Will admission be charged?

    1. Yes
    2. No
    3. Other
63. Type of Event
    -- Select One --CeremonyCelebrationCommunity EventConcertEducation ProgramFestivalFundraiserParadeWedding
65. Will this event have inflatables?*

    1. Yes
    2. No
66. Will this event have food vendors?*

    1. Yes
    2. No
67. Will this event have vendors selling or promoting items?*

    1. Yes
    2. No
69. Event vendors:

    If you answered yes to any of the above questions, we will need a COI listing Pender County as the additional insured.

    Here is how our name and address should appear:

    Pender County

    805 S Walker Street

    PO Box 5

    Burgaw, NC 28425

    
    

    You will also need to send us a list of the food vendors to ensure they're on our approved list and can pay the $25 Food Vendor Fee

71. Description of Event*
73. Flyer for the Event (If Applicable)
77. 
79. I UNDERSTAND THAT SUBMISSION OF THIS APPLICATION DOES NOT MEAN THAT MY APPLICATION HAS BEEN APPROVED. NO RESERVATIONS WILL BE OFFICIAL UNTIL A CONTRACT HAS BEEN SIGNED BY BOTH PARTIES.*

    1. I agree
81. *Application must be submitted 30 days prior to event. I have read and understand the terms and conditions of this reservations and do hereby agree, on behalf of the sponsor of this event, that all persons participating in this event shall adhere and abide by all applicable Ordinances, rules, and regulations*

    1. I agree
83. Additional Documents

    Once your application has been approved you may need to supply the following documents:

    • General Liability Insurance
    • Tax Exemption Certification
    • Non-Profit Documentation
    • Site Map
    • Food Vendor Information
      • General Liability Insurance
      • Copy of Pender County's Health Department Food Establishment
      • Copy of Pender County's Temporary Food Establishment Permit
    • Copy of State Department of Labor Elevator and Amusement Device Bureau Inspection/Authorization
      • Inflatable Rides (e.g. bounce houses)
      • Amusement Rides
      • Stage Platforms, etc.
      • General Liability Insurance
    • Additional requirements for Courthouse Square
      • Temporary Power Service Agreement from Town of Burgaw
      • Trash Hauling Contract
      • Port-o-John Contract
      • Copy of State of Department of Transportation (DOT) and/or Town of Burgaw Street Closure Authorization
85. Are you planning on putting up a banner on Pender County property to promote this event?*
    -- Select One --YesNo
86. If yes,
    Banner Application
88. 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.
90. Electronic Signature
Leave This Blank:


94. 1. Receive an email copy of this form.
95. Email address

    This field is not part of the form submission.

96. Submit

* indicates a required field