FACILITIES LEASE AGREEMENT (WORKSHEET)

Do not click submit at the end of this form, simply fill it out, print it off, and bring it in with you when requesting a room.  This form is simply to aid you in determining what type of setup you need prior to reserving a room.

Name of Leasing Party  

Address of Leasing Party  

Authorized Agent of Leasing Party  

Phone Number(s) of Agent  

Leasing Party is a:   For Profit Entity     Not For Profit Entity

Date Needed     Start Time     Stop Time     Day Needed  

Lease Purpose  

Will There be An Admission Charge?       If So, What Will Be The Rates?   $

Will Food or Beverages Be Served or Sold?       Estimated Attendance  

Total Expected Gate Receipts, If Applicable   $

Area of Building or Room Number Needed  

FACILITY ARRANGEMENTS
Special Features/Equipment Required:

   Bleachers    Scoreboard    Regular PA System - Single Wired Mic
   TV & VCR    O/H Projector    Electrical Connections
   Stage    Serving Tables    Serving Kitchen
   Flip Chart Easel    Marker Board    Telephone Connection
   Other - Specify Below      Special PA System - Specify Below

Special Room Layout Instructions - Note: Only Northark Maintenance Personnel May Move or Reposition Furniture and/or Room Dividers or Partitions

JPH Conference Area Note - Any Intended Use of This Area Requires the Completion of a Separate JPH Conference Area and Seating Layout Form.  A Room Setup Fee May Be Required.

ACCEPTANCE
The Leasing Party Agrees to All Terms, Conditions, and Restrictions As Noted on Back of Form.

Authorized Representative or Agent of the Leasing Party

_________________________________________________________________________________________________________
Signature Date

The Leasing Party Will be Responsible for Security Guards for Inside Crowd Control  

The Leasing Party Will Be Responsible for Cleaning the Premises After the Event  

Fee to Be Charged   $

Northark Approval

_________________________________________________________________________________________________________
Signature Date