DELAWARE COUNTY COMMUNITY COLLEGE
APPLICATION FOR USE OF FACILITIES
Accounting
Plant Operations
Information Technology
Confirmation #
Insurance Expires
Permit Received
Print or Type. Complete All Requested Information. All use will be in accordance with DCCC Facilities Usage Policies.
All items must be completed. If they do not apply please enter N/A.
Date ___________________ You represent a(n): Outside Group ____ College Division _____
Organization Name__________________________________________________________________________________________
Address __________________________________________________________________________________________________
Type of Organization: Corporation ___ Non-Profit Corp. ___ LLC ___ LP ___ Association ___
Contact Person _____________________________________ Phone (Day) _____________________________________
E-mail ____________________________________ Phone (Evening) __________________________________
Program Title ______________________________________________________________________________________________
PROGRAM SCHEDULE
Date(s)
_________________________
Start Time
am / pm End
am / pm
Date(s)
_________________________
Start Time
am / pm End
am / pm
Date(s)
_________________________
Start Time
am / pm
End
am / pm
Date(s)
_________________________
Start Time
am / pm End
am / pm
Number Attending: Minimum ________________ Maximum _________________ Admission Charge: ___________________
AREA REQUESTED Enter quantity of one or more areas. Capacity listed in parentheses
Auditorium – STEM (50)
Cafeteria (200)
Meeting Room (20-35)
Parking Lot
Auditorium – Small (87)
Classroom (25-40)
Student Lounge (50)
Tennis Court (6 Courts)
Auditorium – Large (239)
Computer Lab (33)
Lobby: Academic / Founders Hall
Outside Courtyard
SETUP INFORMATION
Lectern: Yes ___ No ___ Number of Tables _________ Number of Chairs _________
Technology: Computer & Projector ___ Microphone / Speakers ___ Internet Access ___ (See policy regarding Wi-Fi)
Other _________________________________________________________________________________________________
Food: Yes___ No___ If YES, select one: *College Food Service___ Outside Arrangements___
*Outside groups may call 610-359-5068 to request College Food Service
Please specify any County, State, Federal Officials, or News Media invited to event:________________________________________
I AM AUTHORIZED TO SIGN THIS CONTRACT ON BEHALF OF THE ORGANIZATION. I HAVE READ DCCC’S
USE OF FACILITIES POLICY & PROCEDURES AND I AGREE TO ABIDE BY THE RULES DESCRIBED INCLUDING
IMDEMNIFYING DCCC FOR ANY LOSS. I UNDERSTAND THAT I AM NOT TO ADVERTISE OR IN ANY WAY
PROMOTE THIS PROGRAM UNTIL I HAVE RECEIVED WRITTEN APPROVAL FROM DCCC FOR USE OF THE
SPACE.
Signature: ________________________________________ Date: ____________________________________
*** For College Use Only ***
Request: Approved ____ Denied ____ Reviewed /Approved _____________________________ Date ________________
Service Cost $ ___________ Rental Cost $ _____________________ Total Cost $___________________________
Room(s) Assigned
Last Updated: 9/2016
_____________________________________________________________________________________________
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