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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 />❑ Banquet Tables # <br />El Activity Room <br />❑ Chairs # <br />❑ Community Room <br />5?*fA. System <br />❑ Kitchen <br />❑ Other <br />❑ Baseball Diamond <br />❑ Pool <br />r r TIME OF USE <br />FROM l4 _ � V A.M., .M. <br />TO �� A.M., .M. <br />1. Purpose of Activity: GV a `d -n <br />2. Expected Attendance: Adults Z ao <br />Youth 50 <br />3. Is Activity Open to the Public: `, <br />Yes No n <br />4. Will Admission Be Charged: <br />Yes No <br />5. Will Donations Be Accepted: v <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 />Facility/Pool/Fiel rk <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 />Name of 09. <br />anization �, 17 V • �20 -7t,4 7- <br />Name (pleapp print} <br />Title ,. D tAxeI 1 1 _pZ ( ` <br />Address .5q, <br />City, Zip Code 0- 0 (, 7 -OA) / 9,�- 3J - <br />Phone (daytime) L2 cf — S 56 <br />Date — 6 v 1.- ' , 1940 -- <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 />