INSTRUCTIONS:

1). Complete this form, and attach all additional documents, including but not limited to maps, Certificate of
Insurance, and return to Michigan City Clerk’s Office, 100 E. Michigan Boulevard, Michigan City, Indiana.
Read the Board of Public Works & Safety’s Policy Regarding Special Events for Street Closures, copies of
said policy are available in the Clerk’s Office. The Policy prescribes the applicable insurance requirements.

2.) This form and any attachments must be submitted to Clerk at least sixty (60) days in advance of special
event if you are seeking permission to close City street(s) for an event that has never been approved by Board
of Public Works & Safety (“Board”) or a modification to an event which has been previously approved by
Board.

3.) Clerk will forward this information to City Departments for their review and recommendation. In
addition, Clerk will place this Request on the Board’s Agenda for their next public meeting. The Board’s
regular meetings are held on the first and third Monday of every month at 8:30 a.m. in Common Council
Chambers (lower level City Hall). Requests must be received in the City Clerk’s Office by 12:00 p.m.
(C.S.T) on the Wednesday before the scheduled board meeting.

4). You should appear at the Board’s regular meeting to answer any questions or concerns the Board may
have regarding your request.

Date*

Name of Person or Business Entity Requesting Closure: *

Address *

City *

State

Phone Number*

Email*

Date(s) of Event *

Time(s) requested for Event*

Description of Event *

Intersection(s) Seeking Closure for Event*

Number of Estimated Participants in Special Event*

Attach maps, drawings, of area and set-up plan

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

Do you have maps, drawings, of area and set-up plan attached? *

Yes

No

Will alcohol be served or sold? *

Yes

No

If Yes,

Do you have a liquor license? *

Yes

No

Will you be hiring off-duty security?*

Yes

No

How many off-duty security officers will you be hiring?*

Please list names of off-duty security officers:*

Attach Certificate of Liability Insurance

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

Do you have a Certificate of Liability Insurance attached? *

Yes

No

If yes,

Is the City named as an Additional Insured? *

Yes

No

Does it contain a clause that the policy may not be canceled or modify without 30 day advance notice to City?
*

Yes

No

Please list any additional information you believe is relevant to this request: *

I have read the Board of Works & Safety Police regarding Special Events for Street Closures and agree to all the terms and conditions of said policy.

Date*

Name*

Phone*