Request for Municipal Service Authorization Form

Public Service Request for Municipal Service(s)
Authorization for Representation Form

_{It is recommended that requests be submitted at least one month in advance to allow sufficient time for approval. If available at time of submission, please attach applicable documentation (ie. proof of insurance, licenses, permits, permissions). No advertising on Township property or in Township Facilities is permitted until approval has been grented and conditions complied with.}

Name:

is/are hereby authorized to represent

Service Group/Ogranization/Agency

for the purpose of annual municipal service(s) requests for

Year

Or for the purpose of:

Event:

Date:

Signatures of two (2) officers/members of the Service Group/Organization/Agency Requestion Municipal Service(s)

Name:

Position/Title

Email Address:

Phone:

Mailing Address:

Signature:

Clear

Name:

Position/Title:

Email Address:

Phone:

Mailing Address:

Signature:

Clear

Note: Applicant/Organization is responsible for any damages to buildings and/or property as a result of the use. Applicant/Organization agrees to reimburse the Municipality for any damages or cleaning costs.

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