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DURON BUSINESS FORMS 17141878.5160 <br />� 4 v <br />CITY OF COLTON <br />HUMAN SERVICES DEPARTMENT <br />APPLICATION AND AGREEMENT FOR FACILITY USE <br />REQUEST FOR USE OF Fl -_A --=-M I fV [. Pti� Fadlity/Pool/FiekWark <br />(Circle One) <br />ON (DATES) \ it --i 1" IS3 <br />FACILITIES AND EQUIPMENT REQUESTED <br />❑ Multi -use Room <br />❑ Activity Room <br />❑ Community Room <br />❑ Kitchen <br />❑ Baseball Diamond <br />❑ Pool <br />❑ Banquet Tables N <br />Cl Chairs k <br />❑ P.A. System <br />❑ Other <br />TIME OF USE <br />FROM �I ®, P.M. <br />TO A*& <br />1. Purpose of Activity:C1j j-) (LLN 1S <br />P 1 C—NA C <br />2. Expected Attendance: Adults <br />Youths 3 0 <br />3. Is ActivityOpe a Public: <br />Yes No <br />4. Will Admission Be Charged: <br />Yes No &/ <br />5. Will Donations e -Accepted: <br />Yes No <br />If yes, what will the roceeds be used fon <br />CkkJfl_c.Fk NLTiJr�+S <br />We hereby certify that we shall be personally responsible, on <br />behalt of our organization for any damage or unnecessary <br />abuse of buildings, grounds or equipment through the use <br />of said premises by our organization. <br />WE AGREE TO ABIDE 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 APPLICATION. <br />Name of Organization T PVE: P O7(L <br />L, A-ka�'Ti PV -J strip <br />Name (please print) —3 Ot1 y -Ji 3t1116��EL <br />Signature <br />Title CMCS�< <br />Address %`J�'1 C�RF4t�1� iti LjL� <br />City, Zip Code C tk--C„-U-1 0112-1 Z`Y <br />Phone (daytime) -7 F�1 — Q--) % Q Lw <br />Date 310 — L -(Z 1' `I CT 1 s <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 - Offiu <br />Yellow - PM itt" <br />Pink . Fwility <br />Remarks <br />Deb Paid ,19 <br />Date Processed ,19 <br />