Rev 11/02/2017
CITY OF PORTAGE
MUNICIPAL BUILDING COMMUNITY ROOM
APPLICATION FOR USE
Name of Group or Individual:___________________________________
Contact Person:_____________________________________________
Address:__________________________________________________
_________________________________________________________
_________________________________________________________
Telephone Number:__________________________________________
Email Address:______________________________________________
Date of Required Use:________________ Purpose:_________________
Hours of Required Use:_______________ No. of People:_____________
Facility Requested Use Fee
1. Dining Room ______ $25.00
2. Dining Room/Kitchen ______ $50.00
Signature of Applicant
(Representative):_______________________ Date:___________
Date:___________
Rent $_________ Deposit $ 50.00 Total Paid:__________
Receipt #__________ Acct. #100-48-48210-000 Check #_________
Deposit $ 50.00 ($30.00 for the room and $20.00 for the card key)
Card Key Returned ________ Basement Clean ________
Deposit Rt’d $________ Date Rt’d:________
Treasurer’s Signature:_______________________________________
For Office Use Only
Request Approved:___________________________ Dat
e:___________
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