Coastal Alabama Community College
Facility Usage Form
June 2018
Coastal Alabama Community College
Facility Usage Form
Please complete the form below in its entirety and return to:
Questions should be referred to Joni Lambert by email or by phone (251) 580-2207
The College requires all organizations and private businesses to provide a certificate of insurance listing
the College and assignees as additional interest on the policy for the time period of use.
_____ State Gov
_____ Federal Gov
_____ County Gov
_____ SocialOrganization
_____ Charitable Organization
_____ Cultural Organization
_____ Local Gov
_____ Educational Agency/Institute
_____ Political Organization
_____ Professional Organization/Association
End Time (Factor in Breakdown & Clean-up)
End Time (Factor in Breakdown & Clean-up)
Facility/Room Requested:
Date(s) of Event:
Begin Time:
Rehearsal Dates (If Applicable):
Begin Time:
Expected Number of Participants?
Admission/Fee Charged? _____ Y _____ N
If Yes, Amount $ Purpose of Admission:
Will Sales of Services/Products be a part of the Event? Y N
If Yes,
please explain
Is the event Co-sponsored by Coastal Alabama Community College? Y
If yes, provide the name of the College employee who approved this arrangement:
Organization Information
Facility Information
Name of Event: _________________________________________________________________________
Purpose of Event: ________________________________________________________________________
Date: Name:
Name of Organization:
State: Zip:
Phone Number: ____________________ Email Address: _________________________________________________
501C3 Designation: ____ Y ____ N: If Yes, a copy of your IRS designation form must be provided.
Which best describes your organization (you
must check at least one):
Coastal Alabama Community College
Facility Usage Form
June 2018
Equipment Rental Needs:
Sound/Audio Projector Tables/Chairs Wi-Fi
Piano TV/DVD Sound Tech
Podium Video Conferencing Equip.
By signing below, I acknowledge that I have read the Policy for Use of Campus Facilities and that the
information provided on this form is accurate and true.
Signature of Requestor: Position within Your Organization:
____ Approved ____ Denied Date:
Chief Financial Officer
Reason for Denial: _____ Conflicts with College Events Planned _____ Does not meet the mission of the College/ACCS
_____ In Direct Competition with College/ACCS _____ Political Event that is not open to all candidates
_____ For Profit and/or Sales of Services/Products are not allowed unless co-sponsored by Coastal AL.
Date completed application received:
Certificate of Insurance Required: ___Y ___ N Date Certificate of Insurance Received:
501C3 Status ____ Y ____ N Date 501C3 Documentation Received:
MOA mailed/emailed to organization: Date Received signed MOA:
Not-for-Profit: Event to Educate/Raise Awareness _____ Non-Profit: Charity/Fund-Raiser
____ For Profit: Co-Sponsored by Coastal AL
A. Security Required: ____ Y ____ N
________ # of Officers Required
________ Total # of Hours
$_________ Total Amount of Security Fees
B. Facility Usage Fees:
$_______ 1-4 Hours
$_______ 4-8 Hours
$_______ 8 or More Hours
$_________ Total Facility Usage
Clean-Up Fee: ____ Y ____ N $_________ Total Clean-Up Fee
Equipment Rental:
$_______ Equipment: Projector, TV/VCR,
Sound System, Video Conf. Equip.,
$_______ Sound Tech $_______ Piano
$_______ Wi-Fi $_______ Tables/Chairs/Podium
$_________ Total Equip. Rental
E. Port-A-Lets Requested: ____ Y ____ N $_________ Total Cost for Port-A-Lets
$_________ Total Cost
For College Use Only