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VII I %01 VVtan s vs1 ''11 <br />NEIGHBORHOOD SERVICES DEPARTMENT Y � 0 � <br />FACILITY USE APPLICATION AND AGREEMEN 1PR <br />370-6153 <br />REQUEST FOR USE <br />(DATES) 1 Q 9jr <br />FACIUTIES AND EOUIPMENT REQUESTED <br />❑ Main Room <br />O Dar=e Room <br />Activity Room <br />i] Meeting Room <br />Ktchen <br />0 Game Room <br />❑ Baseball Diamond <br />O Tables # <br />4 Crests, e <br />O Pool <br />®PLEASE SUBMIT DIAGRAM <br />OF WJJP MQUE TEO AT <br />LRAST 4e HOURS PAM <br />To SCHEDULMD Un. <br />❑ - Field Lights - Time <br />O - Sn" Bar • Time <br />TIME OF USE <br />FROM —6:n6 A.M.& <br />TO !A 0A.M., P.M <br />1. PurposeofActivity:To tg&&,e L lathy mtrn6cr <br />Pack Nruotti Iserts. <br />2. Expected Attendance: Adults Ir <br />Youths <br />3. Is Activity Open to the Public: <br />No <br />4. Will Admiseton Be Charged:� <br />Yes f No <br />5. Will Donatlons Be Accepted: <br />No <br />M yes. what will the proceeds be used for <br />vTe buy <br />�v1rG Anat]A-i A J �t ue a 12_11., ZL.-_. tel. 7 <br />Application For Facility Use is: <br />Approved Denied <br />By <br />We hereby certify that we shalt be personally responsible, <br />on behalf of ow organization for any damage or <br />unnecessary abuse of buildings, grounds or equipment <br />through the use of said promises by our or nation. <br />WE AGREE TO ALOE BY AND ENFORCE TWE RULES AND <br />REGULATIONS OF THE CITY OF COLTON AND CERTIFY THAT <br />WE HAVE READ THE RULES AND REGULATIONS ON THE <br />BACK OF THIS APPLICATION <br />Name of Orgarszatktn OQ*S <br />=1 <br />Name (please ring Ck AV <br />Signature <br />Tie �ctan�a Te:� r , <br />Address 5 It i E ~% n <br />City. ZIP Code Ol-Tdk1 tot <br />Phone (daytime) $LS- 87'16 <br />Phone (evening),Jdr., 45 Abot,, t <br />Date of application d— 20 t-�- t g `} Q' <br />FOR DEPARTMENT USE ONLY <br />Approval Is Subject To Conditions Listed On Badt <br />Deposit <br />Fee <br />Staff Assigned <br />Date Staff Assigned Time Staff Assigned <br />Assigned by (Supervisor) <br />Remarks <br />Date Paid <br />Data Processed <br />,19 <br />1119 <br />Keys ptcked Up: will <br />t sT <br />White - O m • Canry • Pailnotaa • PMY - FaeyLu . Gelewne - wavae wM a <br />EO'd dEZ=EO QG-TT-,kVW <br />