Name: Date of Request: Organization: Phone Number: E-mail address: Date of Desired Rental: Space Needs: Please check all that apply:
Facilities Use
Amenities Use
Totals w/deposit: $_______________________________________
Commercial Attachments: (circle one) Proof of Insurance – IRS Exemption Letter Hold Harmless Statement – Other: __________________________ Use and/or rental of USSI facilities are at the sole discretion of USSI and/or Agent.
Applicant Signature: __________________________________ Date: _____________ Applicant Signature: __________________________________ Date: _____________ |