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CITY OF COLTON <br />HUMAN SERVICES DEPARTMENT <br />APPLICATION AND AGREEMENT FOR FACILITY USE <br />REQUEST FOR USE OF <br />ON(DATES) <br />FACILITIES AND EQUIPMENT REQUESTED <br />❑ Multi -Use Room Cl Banquet Tables # <br />❑ Activity Room ❑ Chairs If <br />❑ Community Room O P.A. System <br />❑ Kitchen O Other <br />❑ Baseball Diamond <br />O Pool <br />�rjIME OF USE <br />AM.,P.M. <br />auk �y <br />1. Purpose of Activity: <br />2. Expected Attendance: AdultsC-) <br />Youths <br />3. Is ActivityOpe o the Public: <br />Yes No <br />4. Will Admission Be Charged.- <br />Yes <br />harged:Yes No <br />5. Will Donations Be Accepted: <br />Yes No L <br />If yes, what will the proceeds be used for? <br />(0) <br />Fadliry/PooVF <br />(Circle One <br />We hereby certify that we shall be personally responsible, on <br />behalf 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 <br />Name (please <br />Signature <br />Title _6�^__ <br />Address I I " - C �-- <br />City, Zip Code .!) ,//'\ <br />Phone (dayIimel_AUC /I/ S7)f <br />Date '19 <br />FOR DEPARTMENT USE ONLY <br />Application For Facili a Is: <br />Hied <br />BV i � -; f �.✓C-� <br />Approval Is Subject To Conditions isS On Back <br />Fee <br />wNte - office <br />Yellow - Permittee <br />Pink - Facility <br />Goldenrod . Public Works <br />Remarks <br />Date Pad .19 <br />Date Processed <br />19 <br />