Community American Indian Education Center Civic Organizations Parks & Rec Moundview House Little Miami Scenic Trail/Bike Trail Churches & Schools Neighborhoods CRA Program Facility/Grounds Save the Date Name of Facilty/Grounds* Date of Reservation* Date Format: MM slash DD slash YYYY Time of Reservation* 8 AM - 1 PM 2 PM - 10 PM (9 PM on Sunday) All Day * Alchohol Served Alchohol Sold Vendor Name of Individual/Group* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone #1* Phone #2 Activity* Person In Charge* First Last Name of Insurance Company ($1,000,000 minimum)* NOTE: The Village of Newtown is to be listed as an Additional Insured on the Certificate of Insurance (COI) and a copy must accompany this signed agreement. A copy of the driver’s license of the person in charge must be brought to the Newtown Municipal Building. Important Submitting this form only saves the date of your reservation. To complete the agreement, please stop by the Administrative offices at the Newtown Municipal Building. If you have any questions please contact Becky Fairley at (513) 561-7097 or [email protected] Phone This field is for validation purposes and should be left unchanged.