Contact Person* First Name Last Name Booth Name* Company Name Contact Phone*Email Address* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code The application with your donation (detailed below) and all documents listed in the Terms and Conditions must be postmarked by June 24.Please select location(s):* Parade Fireworks @ Stadium Terrace Fireworks @ Research Park Vendor Unit: Parade Price: $150.00 Quantity: Vendor Unit: Fireworks @ Stadium Terrace Price: $150.00 Quantity: Vendor Unit: Fireworks @ Research Park Price: $150.00 Quantity: Size of unit(s):Total $0.00 Menu/Products you will sell:* I certify that I have read all of the information provided in this application, and agree with the Terms and Conditions provided. It is agreed and understood that the completion of the application shall not be binding either to the proposed vendor or to the Champaign County Freedom Celebration until accepted in writing by the Champaign County Freedom Celebration. Promoter has complete decision rights of acceptance. The vendor agrees to assume all loss and hereby indemnifies the Champaign County Freedom Celebration, City of Champaign, City of Urbana, the University of Illinois, its managing board, agents, employees and offices against and agrees to defend and hold them harmless from any and all liability, loss, expense, damage, claims and causes of action arising out of or resulting from or in connection with the vendor’s work or activities.Terms and Conditions* I agree. I acknowledge that the Champaign County Freedom Celebration Terms and Conditions have been received, read and fully understood. I agree to abide by the stated Terms and Conditions, and I understand that failure to comply with the Terms and Conditions can result in refusal of this Vendor application or expulsion from the Champaign County Freedom Celebration.Signature*Date MM slash DD slash YYYY
