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CITY OF COLTON <br />HUMAN SERVICES DEPARTMENT <br />APPLICATION AND AGREEMENT FOR FACILITY USE <br />REQUEST FOR USE OF <br />Facility/Pool/Fiel /Park <br />/� (Circle One <br />ON (DATES) 04 /i r 1 Z 9 L y l Q <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 #t <br />❑ Chairs <br />❑ P.A. System <br />❑ Other <br />TIME OF USE <br />FROM 1.00 A.M., <br />TO ' A. P. M. <br />1. P pose of Activity: <br />con <br />2. Expected Attendance: Adults <br />Youth 1040 <br />3. Is Activity Open to the Public: <br />Yes ✓. No <br />4. Will Admission Be Charged: <br />Yes No <br />5. Will Donations Be Accepted: <br />Yes No <br />If yes, what will the proceeds be used for? <br />Application For Facility Use Is: <br />Approved Denied <br />BY - <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 IND ENFORCE THE RULES AND <br />REGULATIONS OF THE CITY OF COLTON AND CERTIFY <br />THAT WE HAVE READ THE RULES AND REGULATIONS ON <br />THE BACK OF THIS APPLICATION. <br />Name of Organization J '!- M Pro jil (A"I_yC <br />Name (please print) <br />Signature <br />Title V1 co- - S � <br />Address 33 Z D D ra J,'^% e S a ✓W <br />City, Zip Code <br />Phone (daytime) <br />Date _ 3- Z-0 19�_ <br />FOR DEPARTMENT USE ONLY <br />Approval Is Subject To Conditions Listed On Back <br />Deposit <br />White - Office <br />Yellow - Permittee <br />Pink - Facility <br />Goldenrod - Public Works <br />Remarks <br />Date Paid <br />19_ <br />Date Processed '19 <br />