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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/Field/Park <br />no) <br />ON (DATES) 110— 4—��11 (Circle O 7 O d o % _) �� C� O <br />FACILITIES AND EQUIPMENT REQUESTED <br />❑ Multi -Use Room <br />❑ Banquet Tables # <br />El Activity Room <br />❑ Chairs # <br />❑ Community Room <br />&A. System <br />❑ Kitchen <br />y0therkylh i 'I Xg <br />❑ Baseball Diamond <br />❑ Pool <br />L(CC7"Rtari/ <br />TIME <br />OF USE <br />FROM 1 I a <br />lQ Q/A M J PM <br />TO to o <br />O O A.M.O <br />1. Purpose of Activity: p <br />2. Expected Attendance: Adults <br />Youth L <br />3. Is Activity Open to the Public: <br />Yes No <br />4. Will Admission Be Charged: <br />Yes No L\ <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 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 APP <br />.ICAT N. <br />Name of Organ "zation <br />o m, �y a O owl t' izCGs� � �ir fa S <br />Name (please print) %er— n0,kI -�k < <br />Signature -7 d <br />. _ <br />Title <br />Address 9 cl !- <br />City, Zip Code --1821-12A <br />Phone (daytime) %7) It �/ 7 %— Y& � n <br />7 <br />Date — — Ll '19-90— <br />FOR <br />19-9Q <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 '19 - <br />Date <br />1g <br />Date Processed '19 <br />