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DURON BUSINESS FORMS (7111876.5110 <br />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 <br />❑ Activity Room <br />❑ Community Room <br />❑ Kitchen <br />❑ Baseball Diamond <br />❑ Pool <br />Cl Banquet Tables N <br />O Chars N <br />❑ P.A. System <br />❑ Other <br />TIME OF USE <br />M p� �D AM P.M. <br />TO AM. P.M. <br />1. Purpose of Activity:,q e&�E f/7X <br />2. Expected Attendance: Adults <br />Youths <br />3. Is Activity Open to the Public: <br />Yes ✓ No <br />4. Will Admission Be Charged <br />NO W-� <br />5. Will Donations Be Accepted: <br />Yes No 1/ <br />If yes, what will the proceeds be used for? <br />Fadity/Pod/Fi ark ) <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, h/ <br />Name (please print) X-99 <br />�TOr /T7 <br />Signature <br />Title Tb <br />Address <br />City. Zip Code it <br />Phone (daytime) <br />Date <br />19 <br />FOR DEPARTMENT USE ONLY <br />Application For Facility Use Is: Remarks <br />Approved Denied <br />By <br />Approval Is Subject To Conditions Listed On Back <br />P <br />L{+ODO1 <br />,p,,44 Ik "C <br />Fee <br />Date Pad <br />,19__ <br />