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CITY OF COLTON <br />HUMAN SERVICES DEPARTMENT <br />APPLICATION AND AGREEMENT FOR FACILITY USE <br />i <br />REOUEST FOR USE OF ,/-eA I 1A m7c,c�AI&- 1 <br />ON (DATES) �r �'& r' <br />FACILITIES AND EQUIPMENT REQUESTED <br />❑ Multi -Use Room ❑ Banquet Tables # <br />❑ Activity Room ❑ Chairs # <br />❑ Community Room ❑ P.A. System <br />❑ Kitchen ❑ Other <br />❑ Baseball Diamond <br />❑ Pool <br />TIME OF USE <br />FROM 9 A.M., P.M. <br />TO A.M., P.M. <br />1. Purpose of Activity: <br />2. Expected Attendance: Adults AN <br />Youth �Q <br />a Is Activity O en 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 />Facility/Pool/Field; <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 /SND 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 <br />Name (please <br />Signature <br />Title <br />Address —Y -L <br />City, Tip Code_ <br />Phone (daytime) <br />Date _ .3 <br />FOR DEPARTMENT USE ONLY <br />Approval Is Subject To Conditions Listed On Back <br />Deposit <br />Fee <br />Remarks <br />19� <br />Date Paid '19 - <br />White <br />19_ <br />White - Office Date Processed '19 <br />Yellow - Permittee <br />Pink - Facility <br />Goldenrod - Public Works <br />