NOTIFICATION OF INTENT TO HUNT

            The undersigned property owner, after having the opportunity to fully read and understand the City of Clarkson Valley Deer Control Policy, hereby notifies the City of Clarkson Valley of his/her intent to permit archery hunting on the following property:

Owner's Name(s)____________________________________________

__________________________________________________________

Address(es)_________________________________________________

__________________________________________________________

Address(es) of Property to be hunted_____________________________

___________________________________________________________

Dates of Proposed Hunt_______________________________________

The Property owner(s) further certifies the following:

                                                                                             YES          NO

I (We) have provided a certificate of insurance in the

aggregate amount of $2,000,000.00 to City Hall

which provides liability coverage for the hunting activity?          ____          ____

 I (We) have provided a certificate of completion of an

archery device hunter safety course as approved or pro-

vided by the Missouri Department of Conservation?                 ____          ____

I (We) have reviewed and understand the regulations of

the Deer Control Policy                                                               ____         ____

I (We) have received a copy of "Suggested Actions for 

Property Owners"                                                                       ____         ____

All hunters on my property shall be at least 18 years of age.     ____         ____

The property on which the hunt shall occur consists of

at least 1 acre                                                                               ____         ____

or a combination of more than one property owner.

I (We) shall notify all contiguous property owners of the

hunt                                                                                            ____         ____

I (We) or my designated agent (i.e., hunter), shall notify

 City Hall within 2 business days of any deer harvested            ____         ____

If more than one property is involved in a combined hunt, all property owners must sign the indemnity clause and waiver below.

INDEMNITY CLAUSE AND WAIVER

I/We, ____________________________________________________________, in consideration of being authorized to hunt within the corporate limits of the City of Clarkson, agree to abide by the terms and conditions of the Deer Control Policy, as well as all State regulations concerning deer hunting, and I further agree to indemnify and hold harmless the City of Clarkson Valley, for any and all claims which may arise from the hunting activity on my property, whether such claim is based on property damage or personal injury, or whether or not the claim is based on my activity, the activity of my agents or assigns, or if the claim arises on property other than my own, including acts of negligence, and I further agree that this indemnity clause includes the reimbursement to the City of Clarkson Valley for any and all costs of defense, including court costs and attorney fees, in the event that the City is named as a defendant.

____________________________________

Signature

____________________________________

Date