7/15/2020 KDS
Filing Date: ____________________ Campaign Dates Requested: __________________________________
Name of Organization: ________________________________________________________________________
Home Office Address: ________________________________________________________________________
City & State: _____________________________________________Phone: ______________________________
State of Illinois Charter #: ______________________________ Years in Existence: ________________________
Name of Local Chairman: ______________________________________________________________________
Address: ____________________________________________Email: ___________________________________
City & State_________________________________________ Phone: ____________________________
Has your organization solicited in the Village of Niles previously? Yes_________ No__________
If yes, when? _______________________________________________________________________
Describe the nature of your organization and the purpose of your fund-raising efforts:
___________________________________________________________________________________
I certify that the information contained in this application is, to the best of my knowledge, correct and that I
have signed the Hold Harmless Agreement and read the Village of Niles Rules and Regulations for Fund
Drive/Tag Days.
Signature: __________________________________________________Date: ___________________________
Title: _____________________________________________________Phone: __________________________
Return completed form and requested materials to:
Village of Niles
Office of the Village Manager
1000 Civic Center Drive, Niles, IL 60714
Phone: (847) 588-8005; Fax (847) 588-8051; kds@vniles.com
For Office Use Only
Date Received: ______________
Approved Denied
Please submit a Certificate of Liability Insurance. This certificate must show that your
organization has obtained insurance providing coverage for bodily injury liability in the amount
of $1,000,000 for any individual and $1,000,000 for any occurrence. Said policy shall name the
Village of Niles as an additional insured.
