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CITY OF COLTON <br />HUMAN SERVICES DEPARTMENT <br />APPLICATION AND AGREEMENT FOR FACILITY USE <br />I <br />REQUEST FOR USE OF 7-1'e <br />C,'; (DATES) <br />• FACILITIES AND EQUIPMENT REQUESTED <br />C Muiti-Use Room ❑ Banquet Tables # <br />Activity Room <br />Community Room <br />Kitchen <br />3aseball Diamond <br />Pool <br />❑ Chairs # <br />ee" System <br />❑ Other <br />TIME OF USE <br />FROMTi" A.M.,© <br />TO Qty A. M. <br />I. Purpose of Activity: P\n�-�' -) <br />2. Expected Attendance: Adults 75 - <br />Youth SYouth <br />3. Is ^ ?i`�iia open to the Public: <br />'es . No <br />4. Will Admission Be Chargedo- <br />5. <br />: <br />Yes No <br />b`liII Donations Be Accepted- <br />`%es No <br />It +,yes, ;What will the proceeds be used for? <br />Application For Facility Use Is: <br />Approved Denied <br />BY <br />Facility/Pool/Field/Park <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 <br />THAT WE HAVE READ THE RULES AND REGULATIONS ON <br />THE BACK OF THIS APPLICATION. <br />Na a of Organization1� <br />Name (plp.�ri _•c`L �- zr So n <br />Signature <br />Title \-)cOln mbar <br />Address <br />City, Zip Code Q01l 0 r,-- <br />Phone <br />Phone (daytime) <br />Date ��ar \'� �t+ �`� q� 19 <br />FOR DEPARTMENT USE ONLY <br />Approvai Is Subject To Conditions Listed On Back <br />Deposit <br />Fee <br />White -.Office <br />Yellow - Psrmittee <br />Pink - Facility <br />3oldenrod - Public Works <br />Remarks <br />Date Paid t9 <br />Date Processed , 1 g <br />