PERALTA COMMUNITY COLLEGE DISTRICT
COLLEGE OF ALAMEDA
555 Atlantic Avenue
Alameda, CA 94501
(415) 522-7221
LANEY COLLEGE
900 Fallon Street
Oakland, CA 94607
(415) 834-5740
MERRITT COLLEGE
12500 Campus Drive
Oakland, CA 94619
(415) 531-4911
PRINT OR TYPE
Application for Useof Facilities
Date of Application
The
Nameof Organization
Application Number
Through its authorized agent:
Name Title
Street Address
City
Zip Code
Telephone No.
hereby makes appl ication for use of the following facility:
Descri be
Dates and times requested are as follows:
Month Dates
Time Facility
to be Opened:
Time Facility
to be Closed:
State nature of use, title of performance, names of speakers, as appropriate. Describe fully. Use reverse side if necessary.
Number of Attendees
Admission
Fee $
Tickets on Sale at
Are contributions, collections, dues, registration fees or other donations to be received?
Yes No
Amount per Attendee
$
Estimated Total
$
The
applicant
shall be held responsible for any and all loss, accident, neglect, injury or damage to person, life or property which may be the result of, or may
be caused by his or its use or occupancy of the herein described premises. The applicant agrees to protect, defend and indemnify the Peralta Community College
District, its officers, employees and agents and save them harmless in every way from all suits or actions at law for damage or injury to persons, life or property that may arise or be
occasioned in any way because of his or its use of said premises.
The applicant, if requested, agrees and will provide a policy of public liability and property damage insurance for the protection of the public and the lessor
The undersigned states that, to the best of his knowledge, the school property for the use of which application is hereby made will not be used for the com-
mission of any act which is prohibited by law, or for the commission of any crime. I certify
(or declare) under penalty of perjury that the foregoing is true and
correct.
Signature of Applicant
COLLEGE USE ONL Y
Facility and Service Costs:
Facility Cost
Police Services
Grou ndsworker
Maintenance Eng.
Custodian
Technician
Locker Room Atdt.
Equipment Use
$ Costs to be Charged to Applicant?
Yes- No
Public Liability and Property Damage Insurance Required?
Yes- No-
Costs Payment Deadline
Approved:
Signature
Date
Peralta Employee on Site:
TOTAL:
$
BERKELEY CITY COLLEGE
2050 Center Street
Berkeley CA 94704
(510) 981-2840
with limits of not less than $1,000,000 to public liability and $500,000 property damage.
State
*Attach Diagram/Layout for Atrium Set Up - C=Chair, T=Table, P= Podium, M=Microphone, S=Speaker
*
Print Name:
Type/Print N/A If Not Applicable
Form - Must have Adobe Acrobat 7.0
or higher in order to save completed form.
