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Atv i tysuRA EC iNFORMAT10 <br /> r Z <br /> Who is your liability carrier for this event? I {L t % a rk.NANCtz _ <br /> Attach proof of liability insurance in Me amount of One Million Dollars (71,000,000.00.) All <br /> policies shall name the City of Zephyrhills as an additional insured for the event <br /> I/we agree to obtain and maintain the required liability insurance and to secure all necessary <br /> local, state and federal permits and to comply with all terms and conditions applicable to the <br /> conduct of special events, as set forth in Ordinance No. 943 - 05 as amended. <br /> Uwe certify that the information contained in this application is true and accurate to the best of <br /> my /our knowledge. As applicant for the event, I/we agree to release and hold harmless the City <br /> of Zepbyrbills from liability of any Idnd for any and all damages arising out of any loss or <br /> injury resulting from the conduct of this event_ This release includes a release for any and all <br /> losses or injury arising while conducting an event using City of Zepbyrhills facilities or <br /> property and for any and all losses or injury to persons attending this special event. <br /> Uwe certify that individuals will not be barred from participation hi this event due to race, <br /> creed, color, national origin, sex, age, or physical impairment. <br /> By c� -� I �j Date: 3- 3 6 r <br /> pl � <br /> Title: es 1'1-L A.. v� )4 A t u.14A C oryatirl4g - <br /> p <br /> Printed Name; #)P1UJ ' E'«PN Q -+$ J✓I -1—NC - `D pVS[%f J G NfO ~ '' <br /> /t^� �P /4 <br /> 5 ' <br />