Application for Amusement Park License

Application for Amusement Park License
Name of Applicant

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
If a partnership or corporation, list name of partner or officers:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Amusement Park
Location of Amusement Park

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Detailed description and a sketch showing area and showing buildings and improvements and explanation of the method of operation that will be used if license if granted:
I, __________, do swear that the above information is to the best of my knowledge true and correct, and the if granted a license I will abide by all conditions and provisions of the ordinance under which said license is issued.
Signature of Applicant

Clear
Date

MonthDayYear
Date Signed
License fee is $25.00 make your check payable to Village of Somers

Mail To:

Village ot Somers

PO Box 197

Somers, WI 53171

Deliver to Village Clerk:

Village of Somers

7511 12th Street

Somers, WI 53171
Should be Empty: