Name:                                                                    Date of Request:
Organization:
Phone Number:
E-mail address:

Date of Desired Rental:
Space Needs:  Please check all that apply:

 Facilities Use

 

 Auditorium: ______

 

 Hours:______

Minimum (3)

 Total Cost: $__________

Auditorium w/ Lobby:_____

 

 Hours:______

 

 Total Cost: $__________

 Kitchen:_____

 

 Hours:______

 

Total Cost: $__________

 Lobby:_____

 

 

Hours:______

Minimum (3)

 Total Cost: $__________

 Amenities Use

 

 Coffee Pot

 

Total Cost: $__________

 Full Service dinnerware, cookware & utensils 

 Total Cost: $__________

 # Tables (offsite use) _____ 

 Total Cost: $__________

# Chairs (offsite use) ______ 

Total Cost: $__________

 Other: __________________

 (specify)

 

 Total Cost: $__________


Deposit Received:  $_______________________________________

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: _____________