Facility Usage Request – Jubilee Academies

Name of Organization
The name of the organization requesting use of the facility
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Person #1
First Last
Contact #1 Email
Contact #1 Phone
Contact Person #2
First Last
Contact #2 Email
Contact #2 Phone
Nature of Proposed Use
Facility Requested*
Area of Facility Requested
Event Start Date
MM slash DD slash YYYY
Reoccurring Event
- No
- Yes
If reoccurring, please provide additional information in the note box below.
Start Time

: Hours

Minutes

AM/PM
End Time

: Hours

Minutes

AM/PM
Notes (Provide additional information if applicable):
Provide additional information if applicable
Number of participance
Admission Charged
Admission Amount
Attachments Required:
Completed IRS Form W-9
Drop files here or

Max. file size: 2 MB.
Evidence of Non-Profit Status
Drop files here or

Max. file size: 2 MB.
IRS letter denoting 501(c)(3) status
• Evidence of General Liability Insurance with $1,000,000 limits
Drop files here or

Max. file size: 2 MB.
if the application is approved, documentation must be provided that lists Jubilee Academic Center as an Additional Insured on this policy

Attachments Required: