INCORPORATED VILLAGE OF FLORAL PARK     

BLOCK PARTY REQUEST

$25.00 Block Party Application Fee       PLEASE PRINT CLEARLY

We the residents of ______________________________________________________________ between
                                                                      (Street)

__________________________________________________and ______________________________________________
                           (Street)                                                                                           (Street)

hereby request permission to hold a block party on ____________________________________________
                                                                                                                                (Date)

with a rain date of ________________________________. The person(s) responsible for this party is/are
                                                  (Date)

1) Name ___________________________Address __________________________________Phone ________________

2) Name ___________________________Address __________________________________Phone ________________

who has/have agreed to be in attendance for the entire party. By signing this petition in favor of holding the Block Party, we all agree to comply with the regulations set forth in "Regulations for Use of Public Places for Block Parties, Fairs, Picnics and Fundraisers."

YES        NO      SIGNATURE AND ADDRESS OF EVERY RESIDENT ON BLOCK (Use reverse side also)

____      ____      _________________________________________________________________________

____      ____      _________________________________________________________________________

____      ____      _________________________________________________________________________

____      ____      _________________________________________________________________________

____      ____      _________________________________________________________________________

____      ____      _________________________________________________________________________

____      ____      _________________________________________________________________________

____      ____      _________________________________________________________________________

TOTAL NUMBER OF HOMES IN: FAVOR ___________ OPPOSED ___________

IF A RESIDENT IS KNOWN TO BE OUT OF TOWN, PLEASE INDICATE ON THE SIGNATURE LINE ABOVE.

WILL THERE BE ANY MECHANICAL OR INFLATABLE DEVICES? Yes _________ No _________

I HEREBY CERTIFY THAT THE ABOVE SIGNATURES ARE THOSE OF EVERY RESIDENT ON THE BLOCK.                                                                                                                                     

                                                                _______________________________________
                                                                                Signature of Applicant  
 

                                                                _______________________________________
                                                                                Signature of Applicant  


cc: Police Commissioner
      Assessor
     Revised 4/3/09                                          POLICE DEPARTMENT APPROVAL           Date

 

                       ______________________________________________                  ___________