Attachment IV
ALCOHOLIC BEVERAGE
ACTIVITY
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
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