Potsdam Public Library Meeting Room Application

 

NAME OF GROUP REQUESTING USE OF MEZZANINE

 

 

DATE OR DATES OF MEETING

 

 

START AND FINISH TIME OF MEETING

 

 

PURPOSE OF MEETING (ex. Lecture, discussion group, etc.)

 

 

 

 

 

 

NAME OF GROUP’S REPRESENTATIVE (Please Print)

 

 

ADDRESS

 

 

 

TELEPHONE NUMBER:

 

 

DATE REQUEST MADE

 

 

As representative of the above-mentioned group, I agree that the purpose, motivation and nature of the activities to be engaged in within the Library’s meeting room(s) is not for profit.

 

SIGNATURE OF GROUP’S REPRESENTATIVE

 

 

 

SIGNATURE OF LIBRARY PERSONNEL IN CHARGE

 

 

 

DATE RECEIVED

 

APPROVAL OF DIRECTOR

 

DATE OF FINAL APPROVAL