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2. Application Submission Date*
   Application Submission Date
4. First Name*
5. Last Name*
7. Business Name:
9. Main Phone*
10. Alternate Phone
12. Email Address*
14. Billing Address (For Payment Processing) *
16. City*
17. State*
18. Zip Code*
20. Name of Event*
22. Location of Event*
23. Type of Event*
25. Please provide a detailed description of the event*
27. Date of Event*
    Date of Event
28. Beginning Time of Event*
    Beginning Time of Event
29. Ending Time of Event*
    Ending Time of Event
31. Expected Number of Attendees*
32. Will Alcoholic Beverages Be Consumed or Dispensed?*

    1. Yes

    1. No
34. Name Of The On-Site Contact Person
36. First Name*
37. Last Name*
39. Main Phone*
40. Alternate Phone
42. Number of Officers That You Are Requesting*
44. Arrival Time of Officer(s)*
    Arrival Time of Officer(s)
45. Departure Time for Officer(s)*
    Departure Time for Officer(s)
47. What Will The Officer(s) Assignment Be?*

    1. Security

    1. Traffic

    1. Other (Please Specify)
49. Police Equipment Requested

    1. Patrol Car

    1. Boat

    1. Canine
51. Other
    Please specify
53. Submission Details

    Request for off-duty police services shall be made three (3) days prior to the event. Details, such as special or large-scale events, that necessitate advance planning may require the assignment of a Special Event Police Coordinator, who will be compensated at the rate of $51.50 per hour.

    Request for cancellation of off-duty police services must be made at least 24 hours prior to the scheduled starting time of the detail by completing the following form:

    Request to Cancel Off-Duty Police Services

    In addition to the form, notifications of cancellations can be made to the Administrative Coordinator at 305-891-0294 Ext. 24013, Monday through Friday, from 9 PM to 4 PM, excluding holidays. If you are unable to call during the listed hours, you may email the Administrative Coordinator at dsimillien@northmiamipolice.com. Failure to complete this form, canceling your request for off-duty police services within 24 hours, will require a payment of three (3) hours per officer and/or supervisor assigned to the detail. Any questions, please contact the Administrative Coordinator at, 305-891-0294 Ext. 24014.

55. Acknowledgment

    Sign and submit this document by clicking below. Upon signing this form, you agree to the aforementioned requirements.

57. Your Signature
58. Date
    Date
60. ADMINSTRATIVE USE ONLY:

    Name:

    Signature: 

61. APPROVED:
    APPROVED:

    APPROVED:
62. DENIED:
    DENIED:

    DENIED:

    If denied, state reason: 

Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

* indicates a required field