Fillable Application District Facilities Use Rev03092017 Form 2 Ua (Cerritos College)

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Application District Facilities Use Rev03092017 Form 2 Ua (Cerritos College)

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The Application District Facilities Use Rev03092017 Form 2 Ua (Cerritos College) form is 2 pages long and contains:

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  • 48 check-boxes
  • 43 other fields

Country of origin: US
File type: PDF

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___________________________________________________________________
___________________________________________________________________
Cerritos College
Application and Agreement for Use of District Facilities
Contact:
Denise Marshall, Facilities SchedulingCoordinator
11110 Alondra Blvd., Norwalk, CA 90650
Email:
marshall@cerritos.edu Phone: 562.860.2451, Ext. 2303
ORGANIZATION:
Name:_______________________________________ Name of Event: ____________________________________
Address:______________________________________City:_________________State:________Zip Code:
_______
Type of Organization:
_________________ Non-Profit#:____________________________________________
AUTHORIZED REPRESENTATIVE/APPLICANT:
Name/Title:
Business phone number: Ext Mobile Number:
Fax Number: Email Address: _____________________________________
Cerritos College Contact (If Applicable):
DESCRIPTIONOFACTIVITY:
❑
Activity open to the public ❑ Entrance fee charged
❑
Concert
❑
Dance/Theatre
❑
Dining
❑
Filming
❑
Lecture/Speaker
❑
Meeting
❑
Performance
❑
Photo Shoot
❑
Sports Event
❑
Training/Workshop
❑
Web Shoot ❑ Other _____
LOCATION/VENUE
Request is hereby made for use of the following facility:
❑
Athletic Venue: (specify)__________________________
HPEDA Dean Approval:__________________________
❑ Classroom/Lecture Room ❑ Performing Arts Theater
❑Student Center ❑ Special Request/Other: _____________________
❑ Conference Room ❑ Locker Room
❑ Teleconference Room ❑ Utility Field
Date of Event
ExpectedAttendance
Access Time
Event Start Time
Vacate Time
❑
AM
❑
PM
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PM
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PM
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HOLDHARMLESSAGREEMENT
Responsible party entering into agreement: I have read and understand the rules, regulations and policies of the Cerritos
Community College District and assume responsibility for adherence. Organization/Applicant shall be responsible for any damage
sustained on District premises, furniture, or equipment due to the occupancy of said premises. Organization/Applicant agrees
to hold the Cerritos Community College District, its governing board the individual members thereof, and all district officers,
agents, volunteers, and employees free and harmless from any loss, liability, cost or expense that may arise during, or be caused
in any way by, such use of occupancy of District premises. Cancellations require 72-hour notification period. All expenses incurred
by the Cerritos Community College District prior to cancelation are non-refundable.
CERTIFICATE OF INSURANCE/ENDORSEMENT/WORKERS COMPENSATION
$1,000,000.00 minimum liability insurance required. The certificate must identify Cerritos Community College District as
additional insured and be accompanied by an endorsement. District may require increased minimum liability amounts if event
or activity warrants additional coverage.
Organization/Applicant shall maintain workers compensation insurance as required by the
S
tate of California and Employer’s
Liability Insurance.
SIGNATURE
❑
I have reviewed, understand, and agree to abide by the attached District Facility Use Agreement.
Applicant Name/Please Print
Signature/Date
❑Approved ❑ Denied
Organization/Title
Address City
Signature/Date
Director of Physical Plant/Construction Services
Cerritos College
11110 Alondra Blvd.
Norwalk, CA
State Zip code
CERRITOS COLLEGE
OFFICE USE ONLY
ESTIMATED FEE(S): 50% DEPOSIT REQUIRED: ________ (YES/NO)
Facility Rental: ___________
Custodial: ___________ Amount: _________
Security: ___________
Event Mgr.: ___________ Name: __________________________
Parking: ___________
Other: ___________
TOTAL: ___________
Note: Final invoice may vary from estimate due to total event hours, staff hours, damages and/or extra costs.
Final I
nvoice Amt. $
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Application District Facilities Use Rev03092017 Form 2 Ua (Cerritos College)

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Completed 23 July 2020

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