I understand and agree to abide by the Hazen Memorial Library Meeting Room Policy as set forth. I accept personal responsibility on behalf of my organization for use of the Meeting Room.

Name (Please Print):____________________________________________________________

Address (Street, City, Zip):____________________________________________________

Telephone Number (Area Code First):_____________________________________________

Emergency Contact Name:______________________________ Number:______________

Representing (Organization Name):_______________________________________________

Date and Time Requested:________________________________________________________

Purpose of Meeting:_____________________________________________________________

____________________________________________________________________________

Special Requirements (Use of kitchen facility, number of tables, chairs, etc):

____________________________________________________________________________

____________________________________________________________________________

Signature:__________________________________________________________________

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FOR LIBRARY USE ONLY

APPROVED Y____ N____ Date_______________

Name:_______________________________________________________________________

Signature:__________________________________________________________________

Comments:___________________________________________________________________