Application for Facility Use

11227 Racetrack Road, Berlin, Md.  21811          Telephone:  410-641-5433         e-mail:  ccaop@mchsi.com

 

 

 

 

 

Reason for Request:

Facility Requested:

 

WILL THIS USE BE?

 

OneTimeEvent      Date:

Ongoing        Start Date:   End Date:   Day(s) of Week:

                         Start Time: End Time:

Number of People Expected:

Number of Tables Needed:   (Tables will seat up to 8 persons per table)

Number of Chairs Needed:

*Special Equipment / Requirements Requested:

*Setup and take-down by staff is available at additional fee (see Guidelines), otherwise it is the responsibility of the user.

 

 

 

Organization Name:

Responsible Party:

Address:

Telephone:      E-Mail:

To receive a copy of this form re-type E-mail

Contact Person for Group (if other than Responsible Party):

Address:

Telephone:      E-Mail:

 

 

 

ChurchMember/Organization

NotaChurchMember

OceanPinesCommunityOrganization

Non-ProfitOrganization

For ProfitOrganization

 

 

 

I have read the conditions outlined in the "Facility Users Guidelines" Form and agree to abide by same, and to make every effort to insure our guest do likewise, if we are permitted the use of these facilities.

 

 

 

Name:                                                                Date:

 

 

 

 

A Certificate of Liability Insurance Form is Required:   Yes   No          If Yes, Date Form Received:

Request Approved by Office           Activity Placed on Calendar     (by)     Date:

Request Approved by Board of Trustees: Yes      No

Total Fee:                          Deposit:

 Balance Due:                     Date: