Attachment IV




Name of Organization______________________________________ Date_________________


Person Making Request_____________________________________ ID#__________________


Address__________________________________________________ Phone________________




____________ Departmental ____________ Closed Social

____________ Student Organization ____________ Free ________ Charge

____________ Residence Hall ____________ Open (ALL CAMPUS) Social

____________ Other ____________ Free ________ Charge


Type of Beverage__________________________________________


DESCRIPTION OF EVENT_______________________________________________________________


DATE (S) OF EVENT__________________________ TIME ___________ AM/PM__________ 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 race, religion, sex or national origin, (2) such function will normally be restricted to university related groups, (3) appropriate person s will be present at the function to insure the proper use of the facility, (4) such function and use of the facility will not violate any law of the state, rule or regulation of the university. Furthermore the undersigned agrees to (a) reimburse the university for any loss, damage, or expense, and (b) is aware the university will not assume any liability. 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 to dispense alcohol. Police officers must be present unless an exception is granted by the University Police Director or designee.



Signature of Organization President Date



Signature of Sponsor Date




University Police Director/Designee Officers Assigned (No.) Date



Facility Director/Coordinator Date



Food Service/Alcoholic Beverage Contractor Date



Dean of Students/Designee Date