ATTACHMENT IV
ALCOHOLIC
BEVERAGE ACTIVITY
(Print) Name of Person Making
Request____________________________________________________
Texas State
ID#____________________________ Date____________________________
If you are a university employee,
please provide:
Name of Office/Department:
________________________________ E-mail _______________________
Phone ______________________ Is this
a university sponsored event? ___Yes
____No
If you are not a university employee
please provide:
E-mail _____________________________
Phone__________________________
Address_________________________________________________ Phone____________________
TYPE OF ACTIVITY
____________ Departmental ____________ Closed Social
____________ Student Organization ____________ Free __$______ Charge
____________ Residence Hall ____________ Open (ALL CAMPUS) Social
____________ Other (Specify) ____________ Free __$______ Charge
Type of alcoholic beverages to be
made available: ___________________________________________
Type of non-alcoholic beverages to
be made available: _______________________________________
DESCRIPTION OF
EVENT_________________________________________________________________
DATE OF
EVENT______________________________ TIME ___________ AM/PM to __________ AM/PM
LOCATION_________________________________________
ROOM ASSIGNED____________________
ANTICIPATED
ATTENDANCE______________________________________________________________
The undersigned, in connection with
the application to reserve a facility for the event described, certifies that
(1) such function will not be restricted on the basis of color, age,
disability, veterans’ status, sexual orientation, gender identity, and gender
expression, race, religion, sex or national origin (see UPPS No. 04.04.46, Section
01.01), (2) such function will normally be restricted to university-related
groups, (3) appropriate persons will be present at the function to ensure the
proper use of the facility, (4) such function and use of the facility will not
violate any law of the state or rule or regulation of the university.
Furthermore the undersigned agrees to reimburse the university
for any loss, damage, or expense incurred by the university as a result
of the undersigned’s use of the facility, and is aware the university will not
assume any liability for property damage or personal injury, including death,
that may result from or during the undersigned’s use of the facility. Beverage servers must be present at all events in which
alcohol is served and must be seller or server trained through a certified TABC
school and possess a current and valid certification to dispense alcohol. University
police officers must be present unless an exception is
granted by the university.
Signature of Organization President: ________________________________________________
Print_________________________
Date_______________
Signature of Sponsor: ________________________________________________
Print_________________________
Date_______________
Signature of University Police
Director/Designee: ________________________________________________
Print_________________________
Date_______________
Number of
Officers Assigned ______
Signature of Facility
Director/Coordinator: ________________________________________________
Print_________________________
Date_______________
Signature of
Representative of
University Food Contractor (Chartwells) ________________________________________________
Print_________________________
Date_______________
Signature of Dean of
Students/Designee: ________________________________________________
Print_________________________
Date_______________
Contact Information:
Dean of Students Office
LBJ Student Center 512-245-2124
University Police Department
615 North LBJ-Nueces Building
512-245-8336
Chartwells-University Food Contractor
700 Moore Street-Harris Dining Hall
512-245-9930