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Golden Gardens Park In -Water Dog Training Permit Application <br /> 1. Applicant Information: ,f <br /> Name: J�-W £ KQt' Lv tccv�d Phone: 5/ - 6 0 / — 8 ' 730 <br /> Address: I AS at. ►M {D o h Ck. City /Zip: Ell'ei_ 9 <br /> E -Mail Address: k4 Lt t (& Intl_ �l 1. Co "- �J <br /> 2. Animal Information <br /> (Include all dogs to be engaged in in -water training at Golden Gardens Park, list additional dogs on <br /> reverse side): <br /> a) Dog #1 NA C <br /> Breed &Parvw'Gt vt Slew r4-Ini ( y-e( <br /> Color v / ftc� &✓� <br /> Age 3 fS. <br /> Rabies vaccination date '7tg /� <br /> Rabies expiration date '7/01 / <br /> Dog License Number /a55 9 <br /> b) Dog #2 <br /> Breed <br /> Color <br /> Age <br /> Rabies vaccination date <br /> Rabies expiration date <br /> Dog License Number <br /> 3. Signature <br /> I certify that the information I am providing herein is true to the best of my knowledge. I have received a <br /> copy of Administrative Order No XXXX, and the Eugene Park and Open Space Rules, and I agree to <br /> comply with all applicable regulations.I understand that any violation of any provision of the <br /> Administrative Order may result in the City revoking the permit and may be a basis for the City to deny a <br /> future permit application. I agree to indemnify, defend, and hold harmless the City of Eugene, its <br /> officials, agents and employee from and against any and all claims of injury to property or persons that <br /> may arise as a result of in -water dog training activities for which I seek this permit. I agree to pay all <br /> costs of any damage and /or vandalism to the park or facilities used in relation to this permit. <br /> . � ' < cc, 7/q II a lea t <br /> Liv lavid <br /> Signature Date Print Name <br /> {00090457;1 } Golden Gardens Park — In -Water Dog Training Permit Application Page 1 <br />