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W <br />City of South Bend Special Events Committee <br />Indemnity & Hold Harmless Agreement <br />Date: a 3, aD'- Event Date: <br />Event Name: <br />Organization: <br />Applicant (Contact) Name: 0'D1 11I CWVv <br />Applicant (Contact) Phone: 57 `{ - y 4 0 - O 55q Alt. <br />Email: <br />Address: ��U� G'DU2� `�9' City/State/ZIP: 50u-� ('Le-vvok ik3 41Ot5� <br />Event Location (Please describe): <br />Cots--z tr >' <br />Length of Event (Dates/Times): JyVU- L�q aod'-4 ?I 0�� b eV^ <br />APPLICANT agrees to indemnify, defend and hold harmless the Civil City of South Bend, Indiana, from any <br />liability, loss, costs, damages or expenses, including attorney fees, which the Civil City of South Bend, may suffer <br />or incur as a result of any claims or actions which maybe made against the City, its agents, employees, or <br />subdivisions by any person, including a participant in the activity, arising out of the approval of this request by <br />the Civil City of South Bend, Indiana, through the Board of Public Works, to close a portion of the public right-of- <br />way for the event described above, or for any harm or damage alleged to have occurred because of the holding <br />of the special event. The undersigned certifies that he/she is authorized to bind the APPLICANT to these terms. <br />Signed on this Date: ), 01-) I a <br />Organizer Signature <br />1i/11,04IV7 Ca <br />Printed Name and Title <br />