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REQUEST FOR USE OF <br />ON (DATES) <br />CITY OF COLoTON <br />HUMAN SERVICES DEPARTMENT <br />APPLICATION AND AGREEMENT FOR FACILITY USE <br />- Fac71ly/POotiFiekyPefk <br />FACILITIES AND EQUIPMENT REQUESTED <br />❑ I'AA-Use Room 3 Banquet Tables M <br />Act -vitt' Room p Chairs 0 <br />O Community Room Q P.A. System <br />J Kitchen Q Other <br />O Baseball Diamond <br />O Pool <br />TIME OF USE <br />FRori - /� DD A <br />TO A P.11A <br />I . Purpose of Activity: <br />2- Expected Attendarce: Adults <br />youft <br />3. Is Activity Open 10 the Public: <br />Yes _ No <br />4. Will Admission Be Chargee_ <br />Yes _ No ✓ <br />S. Will Donations Be Acrepfed: <br />Yes ----- -- - - No <br />If yes, what will the proceeds be used for? <br />We hereby certify that we shall be personalty responsible, on <br />behalf of our orgartization for any damage or unnecessary <br />abuse of buildings, grounds or Oquiprnenl through the Less <br />Of said Premises by our organization, <br />W9 AGREE TO ASIDE By AND ENFORCE THE RULES AND <br />REGULATIONS OF THE OITy OF COLTON AND CERTIFY THAT <br />WE NAVE READ THE RULES AND REGULATIONS ON THE SACK <br />OF THIS APPLICATION. <br />Name of Organization 7'iriv <br />Name (please print) <br />Signature <br />Title P,tsra.c. <br />Address 3 A <br />City, Zip Code _ g:;{ .e.--rb <br />Phone (daytime) - 6?01. <br />Date <br />FOR DEPAR TMENT USE ONLY <br />Application For Facility Use is <br />Approved _ Denied <br />By <br />Approval Is Subject To Conditws Listed On Back <br />Deposit <br />Fee <br />Who* • oma <br />veliow - pammiptn <br />Pink - F=44 <br />Goldersod • Pubac Wrrks <br />Remarks _ <br />Dole Paid <br />Date Processed <br />19 <br />19 <br />19 <br />ZO'd d£Z=EO 86 -II -AEW <br />