OFFICE OF ADMINISTRATIVE SERVICES
Facilities Use Request for Classrooms by
UH Affiliated Faculty, Staff, and Student Organizations
(For theatre rental, contact directly at 455-0380)
The use of Leeward Community College facilities is governed by policy approved by the University of Hawaii
Board of Regents. These practices and procedures govern the short-term occasional use of campus facilities,
including campus grounds and parking lots by organizations with and without university affiliation.
All requests must be submitted no later than 2 weeks prior to function date to allow review, authorization and
scheduling. Do not publicize event until you have received proper clearance. Failure to follow this schedule may
result in this request being denied. By your signature on this form, the user agrees that all facilities use will be left
in the same condition as before use (i.e. tables and chairs rearranged for a function must be restored to
original set-up, white boards erased, lights turned off, etc.) before leaving.
User category:
1. Registered student organization:
__________________________ / _______________________
(Name of Organization) (Signature of faculty advisor & campus ext.)
Print Name: _____________________________
2. Faculty or Staff organization:
____________________________ / ________________________
(Name of Organization) (Signature of faculty advisor & campus ext.)
Print Name: _____________________________
3. College-recognized organization with the primary purpose of providing service or support to the college:
________________________ / ____________________ Print Name: __________________
(Name of Organization) (Signature of faculty advisor & campus ext.)
Department/Division Chairperson (Print Name: ___________________________________________)
Authorized Signature:
__________________________________ Date: _____________________
Purpose of Event:
______________________________________________________________
Purpose of Use: Public Welcomed?
____ Estimated Attendance? _____ Fees? _____ Amount? ________
DATE(S) REQUESTED:
__________________________________________________________
DAY(S) OF THE WEEK IN USE (CHECK ALL THAT APPLY):
SUN MON TUES WED THURS FRI SAT
TIME OF USE:
_________________________________________________________________
TYPE OF FACILITIES NEEDED:
____________________________________________________
REQUEST: APPROVED / DISAPPROVED
Remarks: (Complete both pages before submitting to AD-112)
NOTE: Computing and/or Audio/Visual equipment should be secured
through your own division office or user’s organization.
Request for additional folding tables & chairs should be submitted to
Operations & Maintenance via a work request.
________
William K. Akama III
Leeward Community College
Office of Administrative Services – Facilities Use
FACILITY ASSIGNED: ___________
Special Set-up Needs:
___________
Open By:
______ Close By: ______
Copies to: Applicant Custodial Security Other:
___________________________
Facilities Use Request Page 1 of 1 Version 4.28.2014
