White-Facilities Yellow-Requestor Pink- CCFL (Retain) Application for Permittee District Facility Use
(Application Fee of $50.00 due at the time of submission. Application Fee will be credited towards event cost.)
Credit Card Authorization Form below
*All fields must be filled out in order for request to be processed*
Name (Requestor):
Application Date:
Phone Number:
Fax Number:
Email Address:
Organization:
Organization Address:
Organization Tax Status:
Profit Non-Profit Non-Profit I.D. #
Permittee Name:
Event Title:
Event Description &
Purpose:
Facility Venue Request:
Please specify Room/Bldg.
Number (If known):
Please indicate the date(s) of your event:
Event Start Time: Event End Time:
Group Entrance Time:
(Start)
Group Exit Time:
(End)
How many attendees are expected?
Please describe your requested venue setup (Be Specific):
Please include number of tables, chairs & equipment
Please check any audio/ visuals you will need for your event: (Note: Some equipment may not be available for some events and/or dates)
Podium
Television
VCR
Video/ Data Projector
Overhead Projector
DVD
Flip Chart(s) #_______
Handheld Microphone
Tabletop Microphone
Portable P/A System
CD Player
Laptop
Portable Screen
Piano
Other:
Does your event require any of the following: YES NO
Stage
Risers
District Catering
Lighting (Theatre/Parking Lots)
Scoreboard/Pressbox
Trash Receptacles
Locker/Team/Green Rooms
District Concessions
Other:
**Please Note: Fees for Custodial & Auxiliary Services will apply for all contracted events (No Fee Waivers) ** Liability Insurance is required for all of contracted events**
Special Instructions:
*Please print, scan & email this form to: swcfacilitiesrental@swccd.edu
*Please print & mail this form to the address above: ATTENTION: Civic Center Facilities Leasing-Office 1633
CCFL Use Only
FUNO #
Received
Approved
Denied
APPLICATION for DISTRICT FACILITY USE
Permittee/Lessee
CIVIC CENTER FACILITIES LEASING
900 Otay Lakes Road * Chula Vista, CA 91910
Phone: 619-482-6319 * Fax: 619-482-6592
White-Facilities Yellow-Requestor Pink- CCFL (Retain) Application for Permittee District Facility Use
Civic Center Facilities & Leasing
900 Otay Lakes Road
Chula Vista, CA 91910
(619) 482-6319
One Time Credit Card Payment Authorization Form
Sign and complete this form to authorize Southwestern Community College District-Civic Center
Facilities & Leasing Department to make a one-time debit to your credit card listed below to be applied to
the SWC Civic Center Facilities & Leasing Agreement/Invoice for event reservation & related services.
By signing this form you give us permission to debit your account for the amount indicated on or after the
indicated date. This is permission for a single transaction only, and does not provide authorization for any
additional unrelated debits or credits to your account.
Please complete the information below:
I ____________________________, a representative of ____________________________ authorize
(Full Name) (Organization Name)
SWC Civic Center Facilities & Leasing to charge my credit card account indicated below for _____________ on or
(Amount)
after ___________________. This payment is for _____________________________________.
(Date) (Description of goods/services)
Billing Address ____________________________ Phone# ________________________
City, State, Zip ____________________________ Email ________________________
Account Type: Visa MasterCard AMEX Discover
Cardholder Name _________________________________________________
Account Number _____________________________________________
Expiration Date ____________
CVV2 (3 digit number on back of Visa/MasterCard, 4 digits on front of AMEX) ______
AUTHORIZED SIGNATURE DATE
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment
authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an
authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms
indicated in this form.
*Please print, scan & email this form to: swcfacilitiesrental@swccd.edu
*Please print & mail this form to the address above: ATTENTION: Civic Center Facilities Leasing-Office 1633
click to sign
signature
click to edit
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