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CITY OF COLTON <br />HUMAN SERVICES DEPARTMENT <br />APPLICATION AND AGREEMENT FOR FACILII <br />REQUEST FOR USE OF� <br />ON (DATES) _ 0`AJ e , `! (/ / j/ �� . ✓ y J <br />FACIUTIES AND EQUIPMENT REQUESTED <br />❑ Multi -Use Room p Banquet Tables ;k <br />O Activity Room CI Chairs E <br />❑ Community Room p P.A.. System <br />O Kitchen ❑ Other. <br />O Baseball Diamond f <br />I] Pool <br />TIM OF USE <br />FROM Sq�30 A1, .M. <br />TO AM. <br />1. Purpose of ctivity: NE r nl P <br />2. Expected Attendance: Adults <br />Youths C� S <br />3. Is Activity Open to the Public: <br />Yes No <br />4. Will Admission Be Charged: <br />Yes No <br />5. Will Donations Be Accepted: <br />Yes No <br />If yes, what will the proceeds be used for? <br />USE <br />One) <br />We hereby certify that we shall be personally responsible, on <br />behalf of our orga iization for any damage or unnecessary <br />abuse of buildings, grounds or equipment through the use <br />of said premises t y our organization. <br />WE AGREE TO ABI DE BY AND ENFORCE THE RULES AND <br />REGULATIONS OF THE CITY OF COLTON AND CERTIFY THAT <br />WE HAVE READ'THE RULES AND REGULATIONS ON THE BACK <br />OF THIS APPLICAIION. <br />Name of Organization P !-+or �1� rr rllcr rc'Uiws,� <br />Name (please, <br />Signature _I <br />Tide <br />Address <br />City, Zip Code <br />Phone (daytim <br />Date <br />FOR DEPARTMENT USE ONLY <br />Application For Facility Use Is: <br />Approved Denied <br />By <br />Approval Is Subject To Conditions Listed On Back <br />Deposit <br />Fee <br />White . office <br />Yellow permittee <br />Pink-, FaciI <br />Goidenrod - Public Works <br />Remarks <br />Date Paid <br />Date Processed <br />t'•L.<<4 <br />,19 <br />,19 <br />,19 <br />