Personal information collected on this form is to assist Council staff to process and assess an application for special events as required by General Local Law 2018, and will be used solely for that purpose. Personal information will not be disclosed to any other person unless required by law. You may apply for access and/or amendment to your personal information by contacting Council’s City Regulatory Services Department.

(herein after called “the Indemnifier”)

to the CITY OF BRIMBANK
(hereinafter called “the Council”)

WHEREAS the Indemnifier has applied to the Council for authority to use portion of a public area within the municipal district under the Council’s General Local Law 2018.

NOW THIS DOCUMENT WITNESSES and confirms that in consideration of the Council granting a permit to set up a structure/activity on Council land

The indemnifier (applicant) agrees to take out and keep current during the period of the permit a liability insurance policy insuring, for a minimum sum of twenty million dollars ($20 million), the applicant against all actions, costs, claims, charges, expenses and damages which may arise under the indemnity set out below.

The applicant agrees to indemnify and keep indemnified the Council, its servants and agents and each of them from and against all actions, costs, claims, charges, expenses, penalties, demands and damages whatsoever which may be brought or made or claimed against them or any of them arising directly from the applicant’s negligent acts, errors or omissions.

The applicant’s liability to indemnify the Council shall be reduced proportionately to the extent that any act or omission of the Council, its servants or agents, contributed to the loss or liability.

Nothing in this Indemnity shall constitute an agreement by the parties to contract out of their respective liability as determined under the Wrongs Act 1958 (Vic).

Name of applicant:
Applicant Address:
Suburb:		Postcode:
Email:		Mobile:
Business Name		ABN:
Billing Address:
Suburb:		Postcode:

Function	[ ] Child’s Birthday. Age:	[ ] Other:
Location	Reserve:	Address:
Date/Time	Date:	From: To:
Structure	[ ] Marquee. Size:	[ ] Jumping Castle. Size:
Activity	[ ] Petting Zoo. Size:	[ ] Other
Attendance	Expected attendance numbers:

SIGNED SEALED AND DELIVERED by:
Name:
In Victoria in the presence of:			(Signature)
Witness:
			(Signature)

Checklist [ ] I have provided a map indicating where hire will be sited (x marks the spot) [ ] I have attached a current copy of my public liability insurance to the value of $20,000,000 valid for the period of the permit
[ ] I have attached written indemnification of Council against any liability for the activity/hire authorised by the permit issued by Council

NOTE: The application will not be processed without the above documentation

at
on the following dates