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2. PROPOSED SPECIAL EVENT
4. Name of the Proposed Event*
5. Date(s)/Time of Proposed Event*
   Date(s)/Time of Proposed Event Start Date

   Date(s)/Time of Proposed Event Start Time

   —

   Date(s)/Time of Proposed Event End Date

   Date(s)/Time of Proposed Event End Time
7. Estimated Number of Attendees*
9. Full Description of Event, including all planned activities*
11. Upload Proposed Event Activities Schedule
13. Location(s) of Proposed Event. Please include the location of any proposed peddlers/itinerant vendors.*
15. Upload Map Identifying Proposed Location, including location of each activity and supporting infrastructure (barricades, porta-potties, parking,etc.)*
19. SPECIAL EVENT ORGANIZER/PROMOTER
21. Organization*
22. Organizer's Contact *
24. Organizer's Telephone Number*
25. Organizer's Email Address*
27. Address*
29. City*
30. State*
31. Zip Code*
33. Is the Organizer/Promoter a corporation or other entity? If Yes, please provide names, addresses and contact info for all officers and directors of the corporation or other entity.*

    1. Yes
    2. No
34. Upload Officers/Directors Info (if applicable)
38. FINANCIAL & INSURANCE INFORMATION
40. Budget for Proposed Event (include anticipated revenues & expenditures)*
41. Certificate of Liability Insurance: In amount as deemed appropriate by Town Manager. If Special Event is expected to exceed 500 people, amount of insurance shall be $1 million. If alcohol is to be served, amount of insurance coverage shall be $3 million. Please attach copy of Certificate of Insurance naming Town of Middleburg as an additional insured.
43. If the Special Event attendance is expected to be 500+ people, evidence of the organization's financial ability to conduct a large event is required.
45. Financial Results of Prior Events
46. Budgets of Prior Events
48. Amount of Contingency Funds Available to Support the Proposed Event
50. Affirmation of No Outstanding Liens, Judgments or Claims

    1. By checking this box, I hereby affirm the organization has no outstanding liens, judgements or claims that may jeopardize its ability to conduct the event.
54. EVENT PLANNING

    Please provide all details associated with the event's planning so the Town Manager may evaluate the organizer's ability to ensure for the public health, safety and welfare of the Town residents and patrons of the Special Event.

56. Plan for Sanitation & Garbage*

    Please provide the plan showing adequate sanitation facilities, including portable restroom locations, and for garbage/trash collection and disposal, as well as sewage disposal.  Plan must be approved by the Town Manager.

57. Plan for Food & Water*

    Please provide the plan for providing food and water for the persons at the event.  Plan must be approved by the County Health Officer.

59. Plan for Parking, Traffic Control & Crowd Control*

    Please provide the plan for adequate parking facilities, traffic control and crowd control in and around the event area.  If the Special Event's attendance is expected to be 500+ people, the parking plan shall be limited to no more than 1,000 parking spaces, regardless of location inside or outside of the town limits in order to ensure there is not an overcrowding of the town, which could affect public health and safety.

60. Plan for Emergency Medical & Fire Response*

    Please provide the plan for adequate emergency medical and fire response for persons in need at the event.  This condition can be met by providing event personnel with cellular phones or other similar devices capable of contacting 911 in an emergency.

62. Plan for Law Enforcement & Public Safety*

    Please provide the plan for providing law enforcement and public safety, including barriers for pedestrian safety, as well as law enforcement officers or security personnel.  If Middleburg Police Officers are requested, the applicant must pay a deposit for any anticipated overtime costs prior to approval of the application (assuming police officers are available for the event).  Use of Middleburg police officers must be approved by the Chief of Police.

63. Plan for Notifying Special Event Attendees of Interruption or Cancellation of Event In Event of Weather or Emergency Situation*

    Please provide the plan for notifying attendees and participants should the Police Chief find it necessary to delay the start of, interrupt or cancel the event as allowed under Town Code Section 6-14.  This plan shall include, but not be limited to, local TV/radio stations; social media platforms; and/or phone alert systems.  The plan shall include phone numbers identified to the applicant's Emergency Contingency Committee and all relevant media outlets. 

65. Plan for Outdoor Lighting (if necessary)

    Please provide the plan for outdoor lighting, if proposed. Plan shall include the location of the lights and shielding devices or other equipment to prevent light trespass beyond the property or right-of-way on which the event is located.

66. Proof of Right-of-Entry/Responsibility of Property Owner

    In the event the Special Event involves the use of private property for parking or other uses necessary or incidental to the event, please provide documentation of right-of-entry by the private property owner to the event organizer and acknowledgement of property owner that he/she/they will take the appropriate steps to ensure the provisions of this Chapter are complied with by the promoters and attendees of the Special Event.  IN NO CASE SHALL THE TOWN OF MIDDLEBURG BE RESPONSIBLE OR LIABLE FOR ANY ACTIVITY OF AN EVENT, EVENT PROMOTER OR ATTENDEES THAT ARE HELD ON PUBLIC PROPERTY, INCLUDING RIGHTS-OF-WAY, AND/OR PRIVATE PROPERTY. 

70. OTHER REQUIREMENTS/MISCELLANEOUS ITEMS
72. By signing this application, I hereby agree to comply with the below conditions (check all that apply or are required)*

    1. If the Special Event is anticipated to have 500+ attendees, to provide the Town Manager with regular recurring updates on the status of the event planning & preparation, as well as an update on the results of the event after it is held.
    2. To comply with all applicable provisions of the Town's Zoning Ordinance (required)
    3. To provide the Town Treasurer/Finance Director with a list of all peddlers and/or itinerant vendors, including names and contact information, participating in the event sufficiently in advance of the event so the Town can collect all applicable fees and/or local taxes. (required)
    4. Upon approval of the application, to provide payment of the deposit for any services provided by the Town, based on the cost estimate, and following the conclusion of the event to pay the invoice for any costs above the estimate within 30 days of receipt of the invoice. (required if Town services provided)
    5. No music shall be audible from the property or right-of-way lines past 10:00 p.m. (required)
    6. To provide copies of all other applicable permits and approvals associated with the Special Event, including but not limited to, those required by Loudoun County, the Virginia Department of Transportation, and the Virginia Alcoholic Beverage Control Authority, prior to the event. (required)
    7. To comply with all provisions of Town Code Chapter 6. (Special Events Permit) (required)
76. 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.
78. Electronic Signature
Leave This Blank:


80. 1. Receive an email copy of this form.
81. Email address

    This field is not part of the form submission.

82. Submit

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