“ CLERMONT ACADEMY”
COMMUNITY
HOUSE
ROUTE
9
CLERMONT,
NEW YORK
APPLICATION FOR USE OF CLERMONT COMMUNITY HOUSE
DATE
OF REQUEST ________________________
NAME
_______________________________________________________________
ADDRESS
____________________________________________________________
PHONE
NUMBER ____________________________________________________
DATE
OF USE OF BUILDING ________________________________________
TIME
_________________________________________________________________
PURPOSE
OF USE/EVENT ___________________________________________
APPROX.
NUMBER ATTENDING ____________________________________
FIRST
FLOOR _____________ FIRST & SECOND FLOOR_____________
I
AGREE TO THE TERMS, AS SET FORTH, FOR THE USE OF THE CLERMONT COMMUNITY
HOUSE.
SIGNED
______________________________________________________________
FOR
OFFICE
USE:
RECEIVED
____________________________
APPROVED/DENIED___________________ PAYMENT
____________
SIGNATURE
___________________________