Dulles International Expressive Activity Permit Application

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Certification

The undersigned individual certifies that they are authorized to submit this Permit application on behalf of the application, that the information furnished above in this application is true and accurate, and that O&I 7-6-1 (as well as the related regulations of the Airports Authority) are for their review, and acknowledges their understanding that the failure to provide in this Permit application all information called for by the Permit application form will result in the application's denial.

1/ When a proposed Expressive Activity involves the Distribution of Printed Material, a copy of the material to be distributed during the proposed activity is to be attached to the submitted application. See Section 6.E(1)(h) of O&I 7-6-1. 2/ When a proposed Expressive Activity involves the Sale of Printed Material or Soliciting that is intended to raise funds on behalf of a charitable, civic or similar organization, documentary evidence that the organization is duly registered (or is exempt from the requirement it be registered) must be attached to the submitted application. See Section 6.E(1)(g). 3/ Designated Areas are described in Section 6.F of O&I 7-6-1 and are shown in Attachments A and B to the O&I. 4/ Dates and times requested for the proposed Expressive Activity: Applicants seeking Permits for multiple dates need to submit a separate application for each date. 5/ Names of each Individual who will participate in the proposed Expressive Activity: See Sections 6.E(1)(d) and 6.E(5) of O&I 7-6-1. 6/ Information regarding individual signing this application on behalf of the applicant: See Section 6.E(1)(a) of O&I 7-6-1.