The Brookfield Library 182 Whisconier Road, Brookfield, CT 06804 203-775-6241 / Fax 203-740-7723 Application for Use of the Community Room Date of Application _____________________________________________________________ Name of Organization ___________________________________________________________ Authorized Representative: Name ___________________________________________________________________ Address _________________________________________________________________ Phone ___________________________ Email __________________________________ Dates Requested Please give Month/Day/Year, Times (from-to) July _____________________________________________________________________________ August _____________________________________________________________________________ September ____________________________________________________________________________ October _____________________________________________________________________________ November _____________________________________________________________________________ December ____________________________________________________________________________ January _____________________________________________________________________________ February _____________________________________________________________________________ March _____________________________________________________________________________ April _____________________________________________________________________________ May _____________________________________________________________________________ June _____________________________________________________________________________ Equipment needed: __ Chairs; Quantity: _____ Arrangement: _________ __ Tables; Quantity: _____ __ Movie Screen __ Stove __ Refrigerator I, the authorized representative of the above named organization, have received a copy of The Brookfield Library’s Policy 600 (Use of the Community Room), including its Rules Governing the Use of the Community Room. I understand that, once signed, this application form signifies my organization’s agreement to pay all fees, and to comply with all rules and conditions specified therein. Signature of Authorized Representative ___________________________________________________ 10/03
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