Facility Use Application

Person or Organization Name(Required)

Person Filing Application(Required)

Organization’s Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Organization’s Purpose(Required)

Date of Usage

Start Time

:

End Time

:

Expected Attendance

Room Set Up Time

Requested Room(s):(Required)

Nature/purpose of gathering

Room set up: (may need to complete a separate room set up diagram)

Equipment request

Billing Information (if different from above)

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Information on Individual Filing Application

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Sponsoring First Presbyterian Church Member

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Signatures & Consent

Signature

Date

Signature

Date

Date Liability Insurance Certificate is due (if applicable)

Date Usage Fees are due: