Full Name *

Date *

Address

Street Address *

City *

State *

Country *

Postal Code *

Phone *

Email *

Standard Amenities:

Parking Lot
Windows that open
Marketing
Standard Maintenance
Restroom
Kitchenette (refridgerator, sink, stove. microwave, coffee pot)
On-site building representative

Signature *

Clear

Printed Name *

Your signature above indicates that you (or your organization) will assume total responsibility or adherence to the considerations listed on pg. 2 as well as for any damages to the facility or its contents, or any loss by theft as a result of your group’s presence: