“ CLERMONT ACADEMY”
COMMUNITY HOUSE
ROUTE 9
CLERMONT, NEW YORK

APPLICATION FOR USE OF CLERMONT COMMUNITY HOUSE


DATE OF REQUEST ________________________

NAME _______________________________________________________________

ADDRESS ____________________________________________________________

PHONE NUMBER ____________________________________________________

DATE OF USE OF BUILDING ________________________________________

TIME _________________________________________________________________

PURPOSE OF USE/EVENT ___________________________________________

APPROX. NUMBER ATTENDING ____________________________________

FIRST FLOOR _____________ FIRST & SECOND FLOOR_____________

I AGREE TO THE TERMS, AS SET FORTH, FOR THE USE OF THE CLERMONT COMMUNITY HOUSE.

SIGNED ______________________________________________________________

FOR OFFICE USE:
RECEIVED ____________________________
APPROVED/DENIED___________________ PAYMENT ____________
SIGNATURE ___________________________