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E
E
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A
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External
External
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Facilities Use Onl
Banner ID #:
Jefferson Community Colleg
e
_______________________
1220 Coffeen Street
Watertown, NY 13601
Samuel Guthrie Bldg., Room 2‐012
(315) 786‐2405
Please read the attached guidelines before signing. Fill in all information and return the completed form to the Facilities Secretary
at least 45 days prior to the scheduled event. All events are subject to cancellation by JCC Administration. Please print clearly and
complete all boxes for proper processing.
Purpose of Event:
Event Name:
Today’s Date: Name of Organization : Contact Person:
Contact Phone: ( ) ‐ Fax: ( ) ‐ Contact Day of Event: Phone: ( ) ‐
Organization Address: Contact person email:
BILLING INFORMATION
If billing address is same as organization address, please check box:
Party Responsible for Bill: Responsible Party Email:
Responsible Party Address: Responsible Party City, State, Zip Code:
Responsible Party Phone : ( ) ‐ Responsible Party Fax: ( ) ‐ Estimated Number of Attendees:
CO SPONSORING ORGANIZATION
Co‐Sponsoring Organization: Co‐Sponsoring Organization Contact: Co‐Sponsoring Organization Email:
Co‐Sponsoring Organization Contact Phone: ( ) ‐ Co‐Sponsoring Organization Fax: ( ) ‐
Are any participants under the age of 17? Yes No
Schedule of Events
Please be specific on actual arrival times, performance times, and set‐up times, AM or PM
Date Day Applicant Set‐Up Time Actual Event Hours Applicant Tear‐Down Hours
to to to
to to to
to to to
to to to
to to to
to to to
to to to
Will there be an admission charge for this event?
Yes No
If yes, how much?
Are you a Not for Profit Agency?
Yes No
Will the contract be signed by the requestor?
Yes No
If no, who will sign the contract?
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