Common use of For Office Use Only Clause in Contracts

For Office Use Only. Total Amount Paid $ Check # ; Date Pd: Number of Guests: Security Deposit*: $ Building Rental Fee: $ Alcohol Rental Fee: $ *The security deposit is to cover any damage to the facility, violations of the rental agreement, extra clean-up or cancellation of event without 3 weeks notice. Payment Instructions: • Deposits and rental fees are payable at booking to reserve the building. • Checks made payable to: City of Xxxxxx. • Any payments made by personal check must be received by the City of Xxxxxx at least three weeks in advance of the event. If received within three weeks of the event, it must be submitted in the form of a cashier’s check or cash. • All checks for rental fees and security deposits are cashed upon receipt, not held. XXXXX COMMUNITY BUILDING Mailing Address: City of Xxxxxx 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 Phone: (000) 000-0000 CITY OF XXXXXX Located: 0000 Xxxx Xxxxx Xxxxxx, XX 00000 Xxxxx Community Building Damage Survey Please inspect the facility prior to your rental date and note any existing damages to the facility to make sure you will not be liable for damages done prior to your event. Circle in red the damaged locations on the layout and describe the damages on the lines below. X X Assembly Room Food Service Area Storage Rooms Bathrooms Ceiling Area Other XXXXX COMMUNITY BUILDING CLEANING CHECKLIST • Empty all garbage cans and recycle bins even if small amount in can o Replace can liners • Wipe all tables with disinfectant soap • Please put all tables and chairs away correctly o Tables like sides together o Chairs as directed on wheeled carts • Vacuum main room carpet and all rugs including front entry o IF CARPET IS WET, PLEASE USE CARPET CLEANER INSTEAD OF VACUUM • Wipe main door glass of handprints and smears • Wipe down food service area (kitchen) with disinfectant spray o Wipe counters, appliances and sink • Sweep and Mop: o Front entry o Men’s restroom o Women’s restroom o Food service area (kitchen) (Mop found in mechanical room behind door with xxx xxxxxx) • Clean Men’s and Women’s restroom o Wipe vanities, sink and faucets o Clean toilets and urinals o Clean mirrors o Empty all waste receptacles in stalls • Before exiting, please put furnace/air thermostat on “Continuous Unoccupied” setting • Leave key under office door Frequently Asked Questions—Xxxxx Community Building How do I rent the Xxxxx Community Building? After checking the online calendar for openings, call Xxxxx Lions representative Xxxxx Xxxxx at 000-000-0000 to confirm availability of your dates. You may then print a contract and special function sheet, fill them out and send them to the City of Xxxxxx with a check for the deposit and rental fees to hold your day. The fee schedule for rental fees and deposits are posted on the website. Who do I make the check payable to? The City of Xxxxxx Can I write out one check for the deposit and the rental fee? Yes, please write one check for the total amount (rental fee + deposit). All security deposit and rental fees made by personal check shall be received by the City of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted in the form of a cashier’s check or cash. All checks for rental fees and security deposits are cashed upon receipt, not held. Where do I send the contract and check? Send to: City of Xxxxxx Attn: Xxxxx Community Building 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 When are the Security Deposit and Rental Fee due? The security deposit and rental fee are due at the time of signing the Rental Agreement. Your rental date will not be guaranteed until the city has received your security deposit, rental fee, and the signed rental agreement. Security deposit and rental fees made by personal check shall be received by the City of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted in the form of a cashier’s check or cash. All checks for rental fees and security deposits are cashed upon receipt, not held. Is the Community Building in Xxxxx or Medina? It is in the community/neighborhood of Xxxxx, but it is in the City of Xxxxxx. What are the directions to the Xxxxx Community Building? The community building is located at 0000 Xxxx Xxxxx, directly behind Farmers State Bank of Xxxxx off of Xxxxx Road. When coming off of Highway 55, turn South on Xxxxx Road or Sioux Drive into Uptown Xxxxx. Who is responsible for setting up the room and cleaning up afterwards? The person or group renting the building is responsible for the building. Please review the cleaning check list attached to your rental agreement. How many tables are available? When renting the Community Building there are fifteen (15) five foot round tables that seat 7-8 people and fifteen (15) eight foot rectangular tables that seat 8-10 people. How many chairs are available? When renting the Community Building there are 120 non-folding chairs and 17 folding chairs available. How do I get a key to the facility for my event? Your key to the Xxxxx Community Building will be given to you by appointment before your event or you will be given the code to the lock box. Call Xxxxx Xxxxx at 000-000-0000 for a convenient time. If I have rented items from elsewhere that are to be picked up, do I need to be there? Yes! You are responsible for the building and its contents when pick ups occur. Please make arrangements with the company for time of pick up. Remember, the Xxxxx Community Building does not have regular open hours so you must let them into the building. How do I get my security deposit back? After your event, a HCB representative will assess the building and check for damage, proper put away and clean up. If all is satisfactory, a check will be sent back to you in the mail. It takes two- three weeks to receive your returned deposit check. If there are inadequacies in the above, the City of Xxxxxx will assign a fee and issue the remaining balance of your deposit check. Remember that you as the renter are responsible for any damage done by contractors or caterers you hire for your event. Is alcohol allowed to be served at the Xxxxx Community Building? Yes, but the renter must comply with all the terms in the rental contract pertaining to alcohol. How do I purchase insurance naming the City of Xxxxxx as an additional insured for my event that I am serving alcohol at the HCB? One option would be to call your homeowners or business insurance company and ask if they could produce a certificate of insurance naming the City of Xxxxxx as an additional insured in the amount of $1,000,000 for the day of your event at the Xxxxx Community Building. If this option fails, another option would be to purchase insurance through the City of Medina’s insurance company’s tenant user liability insurance program (TULIP). To get a quote or purchase insurance for your event go to xxx.xxxxxxxxxxxxxxxxxxxxxx.xxx and click on “TULIP (Purchase or Quote)” and enter the facility code: 0501-AZ7. Where do I call if I have more questions?

For Office Use Only. Total Rental Amount Paid $ Check # ; Chisago City Resident discount 10% My rental is for the date(s) and times specified above only. Changing a date shall be treated as a cancellation and the reserve deposit forfeited. I understand and agree to the rental agreement. Renter’s Signature Date PdCity Official’s Signature Date STORM SHELTER IS XXXXX XXXX BASEMENT ~SMOKING IS PROHIBITED~ *Please return completed form to: Number of GuestsChisago City Hall, PO Box 611, 00000 Xxxxxxxx Xxx., Xxxxxxx Xxxx, XX 00000 Or Email: Security xxxxxxx@xx.xxxxxxx.xx.xx Copy to: Renters City Hall Police Decorating: 3M COMMAND OR SCOTCH WALLSAVER REMOVABLE TAPE are the only products allowed for decorating. No confetti, rice, string streamers, nails or tacks. Expenses incurred by damage caused by decorating will be deducted from your deposit. Nothing hung from ceiling or lights. Depending on availability, I may rent the center for decorating purposes the evening before my event. Additional costs will apply. This fee must be paid prior to the event. Deposit*: $ Building Rental Fee: $ Alcohol Rental Fee: $ *The security Deposits must be paid before the facility can be held for reservations. Checks for the deposit is to cover will be cashed immediately. After the event, any damage and/or clean-up cost remaining will be deducted from the deposit. The clean-up deductions will be based on whether or not the clean-up after my event was satisfactory. This will be determined by the caretaker. I will notify Chisago City staff of any damages accrued during my rental of the Ojiketa building. Damages may include, but are not limited to: damage done to the facility, violations equipment, or any City property. The full amount or the remaining amount of my deposit will be sent to the rental agreement, extra clean-up or cancellation address listed above. Tables and chairs: Tables and chairs will be provided. The renter is responsible for arranging tables and chairs for their event. The renter is not responsible for taking down the tables. Chairs must be stacked at edge of event without 3 weeks noticefloor after your event. Payment Instructions: • Deposits Tables and rental fees are payable at booking to reserve chairs shall not be removed from the building. • Checks made payable to: City of Xxxxxx. • Any payments made by personal check must be received by the City of Xxxxxx at least three weeks in advance of the event. If received within three weeks of the event, it must be submitted in the form of a cashier’s check or cash. • All checks for rental fees and security deposits are cashed upon receipt, not held. XXXXX COMMUNITY BUILDING Mailing Address: City of Xxxxxx 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 Phone: (000) 000-0000 CITY OF XXXXXX Located: 0000 Xxxx Xxxxx Xxxxxx, XX 00000 Xxxxx Community Building Damage Survey Please inspect the facility prior to your rental date and note any existing damages to the facility to make sure you will not be liable for damages done prior to your event. Circle in red the damaged locations on the layout and describe the damages on the lines below. X X Assembly Room Food Service Area Storage Rooms Bathrooms Ceiling Area Other XXXXX COMMUNITY BUILDING CLEANING CHECKLIST • Empty all garbage cans and recycle bins even if small amount in can o Replace can liners • Wipe all tables with disinfectant soap • Please put all tables and chairs away correctly o Tables like sides together o Chairs as directed on wheeled carts • Vacuum main room carpet and all rugs including front entry o IF CARPET IS WET, PLEASE USE CARPET CLEANER INSTEAD OF VACUUM • Wipe main door glass of handprints and smears • Wipe down food service area (kitchen) with disinfectant spray o Wipe counters, appliances and sink • Sweep and Mop: o Front entry o Men’s restroom o Women’s restroom o Food service area (kitchen) (Mop found in mechanical room behind door with xxx xxxxxx) • Clean Men’s and Women’s restroom o Wipe vanities, sink and faucets o Clean toilets and urinals o Clean mirrors o Empty all waste receptacles in stalls • Before exiting, please put furnace/air thermostat on “Continuous Unoccupied” setting • Leave key under office door Frequently Asked Questions—Xxxxx Community Building How do I rent the Xxxxx Community Building? After checking the online calendar for openings, call Xxxxx Lions representative Xxxxx Xxxxx at 000-000-0000 to confirm availability of your dates. You may then print a contract and special function sheet, fill them out and send them to the City of Xxxxxx with a check for the deposit and rental fees to hold your day. The fee schedule for rental fees and deposits are posted on the website. Who do I make the check payable to? The City of Xxxxxx Can I write out one check for the deposit and the rental fee? Yes, please write one check for the total amount (rental fee + deposit). All security deposit and rental fees made by personal check shall be received by the City of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted in the form of a cashier’s check or cash. All checks for rental fees and security deposits are cashed upon receipt, not held. Where do I send the contract and check? Send to: City of Xxxxxx Attn: Xxxxx Community Building 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 When are the Security Deposit and Rental Fee due? The security deposit and rental fee are due at the time of signing the Rental Agreement. Your rental date will not be guaranteed until the city has received your security deposit, rental fee, and the signed rental agreement. Security deposit and rental fees made by personal check shall be received by the City of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted in the form of a cashier’s check or cash. All checks for rental fees and security deposits are cashed upon receipt, not held. Is the Community Building in Xxxxx or Medina? It is in the community/neighborhood of Xxxxx, but it is in the City of Xxxxxx. What are the directions to the Xxxxx Community Building? The community building is located at 0000 Xxxx Xxxxx, directly behind Farmers State Bank of Xxxxx off of Xxxxx Road. When coming off of Highway 55, turn South on Xxxxx Road or Sioux Drive into Uptown Xxxxx. Who is responsible for setting up the room and cleaning up afterwards? The person or group renting the building is responsible for the building. Please review the cleaning check list attached to your rental agreement. How many tables are available? When renting the Community Building there are fifteen (15) five foot round tables that seat 7-8 people and fifteen (15) eight foot rectangular tables that seat 8-10 people. How many chairs are available? When renting the Community Building there are 120 non-folding chairs and 17 folding chairs available. How do I get a key to the facility for my event? Your key to the Xxxxx Community Building will be given to you by appointment before your event or you will be given the code to the lock box. Call Xxxxx Xxxxx at 000-000-0000 for a convenient time. If I have rented items from elsewhere that are to be picked up, do I need to be there? Yes! You are responsible for the building and its contents when pick ups occur. Please make arrangements with the company for time of pick up. Remember, the Xxxxx Community Building does not have regular open hours so you must let them into the building. How do I get my security deposit back? After your event, a HCB representative will assess the building and check for damage, proper put away and clean up. If all is satisfactory, a check will be sent back to you in the mail. It takes two- three weeks to receive your returned deposit check. If there are inadequacies in the above, the City of Xxxxxx will assign a fee and issue the remaining balance of your deposit check. Remember that you as the renter are responsible for any damage done by contractors or caterers you hire for your event. Is alcohol allowed to be served at the Xxxxx Community Building? Yes, but the renter must comply with all the terms in the rental contract pertaining to alcohol. How do I purchase insurance naming the City of Xxxxxx as an additional insured for my event that I am serving alcohol at the HCB? One option would be to call your homeowners or business insurance company and ask if they could produce a certificate of insurance naming the City of Xxxxxx as an additional insured in the amount of $1,000,000 for the day of your event at the Xxxxx Community Building. If this option fails, another option would be to purchase insurance through the City of Medina’s insurance company’s tenant user liability insurance program (TULIP). To get a quote or purchase insurance for your event go to xxx.xxxxxxxxxxxxxxxxxxxxxx.xxx and click on “TULIP (Purchase or Quote)” and enter the facility code: 0501-AZ7. Where do I call if I have more questions?DO NOT DRAG TABLES OR CHAIRS ACROSS FLOOR.

For Office Use Only. Total Approved and Accepted by: ____ Deposit Amount Paid $ Check  Check # ; _________ Cash  Credit Card Authorization#______________ Visa  MC  Other:  Date PdApproved: Number TOWN OF XXXXXX WATER DEPARTMENT – SERVICE AGREEMENT The Town shall sell and deliver water and/or wastewater service to the Applicant and the Applicant shall purchase, receive, and/or reserve service from the Town in accordance with the Ordinances adopted by the Town. The Applicant shall pay the Town for service hereunder as determined by the Town’s Ordinances. A copy of Guests: Security Deposit*: $ Building Rental Fee: $ Alcohol Rental Fee: $ *this agreement shall be executed before service may be provided to the Applicant. The security deposit City Council shall have the authority to discontinue service of Applicant not complying with any policy or not paying any utility fees or charges as required by the Town’s Ordinances, fees, and conditions of service. If, at any time, service is discontinued, terminated, or suspended, the Town shall not reestablish service unless it has a current, signed copy of this agreement. All water shall be metered by meters to be furnished and installed by the Town. The meter and/or wastewater connection is for the sole use of the Applicant and is to cover provide service to only one (1) dwelling or one (1) business. Extension of pipe(s) to transfer utility service from one property to another, to share, resell, or sub meter water to any damage other persons, dwellings, businesses, or property, etc., is prohibited. The Town shall have the right to locate a water service meter and the pipe necessary to connect the meter on the Applicant’s property at a point to be chosen by the Town and shall have access to its property and equipment located upon Applicant’s premises at all reasonable and necessary times for any purpose connected with or in the further operation of its business operations, and upon discontinuance of service. During construction grading, landscaping, etc. if the meter box is damaged or broken, there will be a charge of $100.00 for replacement of the meter box unless it is a Badger Radio Read meter, then the price is $250.00 and up. All locations connected to the facilityTown of Ponders Water System will have a cut-off between the meter box and the building, violations barn, etc. The Town is responsible for protecting the drinking water supply from contamination or pollution which could result from improper plumbing practices. This service agreement serves as notice to each Applicant of the rental agreementplumbing restrictions which are in place to provide this protection. The Town shall enforce these restrictions to ensure the public health and welfare. The following undesirable plumbing practices are prohibited by state regulations: No direct connection between the public drinking water supply and a potential source of contamination is permitted. Potential sources of contamination shall be isolated from the public water system by an air gap or an appropriate backflow prevention assembly in accordance with state plumbing regulations. Additionally, extra clean-up or cancellation of event without 3 weeks notice. Payment Instructions: • Deposits all pressure relief valves, and rental fees are payable at booking to reserve the building. • Checks made payable to: City of Xxxxxx. • Any payments made by personal check thermal expansion devices must be received in compliance with state plumbing codes. No cross-connection between the public drinking water supply and a private water system is permitted. These potential threats to the public drinking water supply shall be eliminated at the service connection by the City proper installation of Xxxxxx an air gap or a reduced pressure-zone backflow prevention assembly and a service agreement must exist for annual inspection and testing by a certified backflow prevention device tester. No connection which allows condensing, cooling, or industrial process water to be returned to the public drinking water supply is permitted. No pipe or pipe fitting which contains more than 8.0% lead may be used for the installation or repair of plumbing on or after July 1, 1988, at least three weeks any connection which provides water for human consumption. No solder or flux which contains more than 0.2% lead may be used for the installation or repair of plumbing on or after July 1, 1988, at any connection which provides water for human consumption. The Town shall maintain a copy of this agreement as long as the Applicant is connected to the public water system. The Applicant shall allow his property to be inspected for possible cross connections and other undesirable plumbing practices. These inspections shall be conducted by the Town or its designated agent prior to initiating service and periodically thereafter. The inspections shall be conducted during the Town’s normal business hours. The Town shall notify the Applicant in advance writing of any cross-connections or other undesirable plumbing practices which have been identified during the eventinitial or sub sequent inspection. The Applicant shall immediately correct any undesirable plumbing practice on their premise. The Applicant shall, at his expense, properly install, test, and maintain any backflow prevention device required by the Town. Copies of testing and maintenance records shall be provided to the Town as required. Failure to comply with the terms of this service agreement shall cause the Town to terminate service or properly install, test, and maintain an appropriate backflow prevention device at the service connection. Any expenses associated with the enforcement of this agreement shall be billed to the Applicant. If received within three weeks of the eventa sprinkler system is installed, it must be submitted in the form of under a cashier’s check or cash. • All checks for rental fees separate permit and security deposits are cashed upon receipt, not held. XXXXX COMMUNITY BUILDING Mailing Address: City of Xxxxxx 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 Phone: (000) 000-0000 CITY OF XXXXXX Located: 0000 Xxxx Xxxxx Xxxxxx, XX 00000 Xxxxx Community Building Damage Survey Please inspect the facility prior to your rental date and note any existing damages to the facility to make sure you will not be liable for damages done prior to your event. Circle in red the damaged locations on the layout and describe the damages on the lines below. X X a completed “Backflow Prevention Assembly Room Food Service Area Storage Rooms Bathrooms Ceiling Area Other XXXXX COMMUNITY BUILDING CLEANING CHECKLIST • Empty all garbage cans and recycle bins even if small amount in can o Replace can liners • Wipe all tables with disinfectant soap • Please put all tables and chairs away correctly o Tables like sides together o Chairs as directed on wheeled carts • Vacuum main room carpet and all rugs including front entry o IF CARPET IS WET, PLEASE USE CARPET CLEANER INSTEAD OF VACUUM • Wipe main door glass of handprints and smears • Wipe down food service area (kitchen) with disinfectant spray o Wipe counters, appliances and sink • Sweep and Mop: o Front entry o Men’s restroom o Women’s restroom o Food service area (kitchen) (Mop found in mechanical room behind door with xxx xxxxxx) • Clean Men’s and Women’s restroom o Wipe vanities, sink and faucets o Clean toilets and urinals o Clean mirrors o Empty all waste receptacles in stalls • Before exiting, please put furnace/air thermostat on “Continuous UnoccupiedTest Report” setting • Leave key under office door Frequently Asked Questions—Xxxxx Community Building How do I rent the Xxxxx Community Building? After checking the online calendar for openings, call Xxxxx Lions representative Xxxxx Xxxxx at 000-000-0000 to confirm availability of your dates. You may then print a contract and special function sheet, fill them out and send them to the City of Xxxxxx with a check for the deposit and rental fees to hold your day. The fee schedule for rental fees and deposits are posted on the website. Who do I make the check payable to? The City of Xxxxxx Can I write out one check for the deposit and the rental fee? Yes, please write one check for the total amount (rental fee + deposit). All security deposit and rental fees made by personal check shall be received by the City of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted to the permitting office. An inspection must be done every year and submitted to the permitting office. If the sprinkler system is constructed in the form of a cashierTown’s check or cash. All checks for rental fees utility easement and security deposits are cashed upon receiptthe Town needs to make repairs to the water/sewer lines, not held. Where do I send the contract and check? Send to: City Town of Xxxxxx Attn: Xxxxx Community Building 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 When are the Security Deposit and Rental Fee due? The security deposit and rental fee are due at the time of signing the Rental Agreement. Your rental date will is not be guaranteed until the city has received your security deposit, rental fee, and the signed rental agreement. Security deposit and rental fees made by personal check shall be received by the City of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted in the form of a cashier’s check or cash. All checks for rental fees and security deposits are cashed upon receipt, not held. Is the Community Building in Xxxxx or Medina? It is in the community/neighborhood of Xxxxx, but it is in the City of Xxxxxx. What are the directions to the Xxxxx Community Building? The community building is located at 0000 Xxxx Xxxxx, directly behind Farmers State Bank of Xxxxx off of Xxxxx Road. When coming off of Highway 55, turn South on Xxxxx Road or Sioux Drive into Uptown Xxxxx. Who is responsible for setting up the room and cleaning up afterwards? The person or group renting the building is responsible for the building. Please review the cleaning check list attached to your rental agreement. How many tables are available? When renting the Community Building there are fifteen (15) five foot round tables that seat 7-8 people and fifteen (15) eight foot rectangular tables that seat 8-10 people. How many chairs are available? When renting the Community Building there are 120 non-folding chairs and 17 folding chairs available. How do I get a key to the facility for my event? Your key to the Xxxxx Community Building will be given to you by appointment before your event or you will be given the code to the lock box. Call Xxxxx Xxxxx at 000-000-0000 for a convenient time. If I have rented items from elsewhere that are to be picked up, do I need to be there? Yes! You are responsible for the building and its contents when pick ups occur. Please make arrangements with the company for time of pick up. Remember, the Xxxxx Community Building does not have regular open hours so you must let them into the building. How do I get my security deposit back? After your event, a HCB representative will assess the building and check for damage, proper put away and clean up. If all is satisfactory, a check will be sent back to you in the mail. It takes two- three weeks to receive your returned deposit check. If there are inadequacies in the above, the City of Xxxxxx will assign a fee and issue the remaining balance of your deposit check. Remember that you as the renter are responsible for any damage done to the sprinkler system. By execution hereof, the Applicant shall hold the Town harmless from all claims for damages caused by contractors service interruptions due to waterline breaks by utility or caterers you hire like contractors, tampering by other Applicants of the Town, normal failures of the system or other events beyond the Town’s control. The Applicant shall grant to the Town, now or in the future, any easements of right-of-way for your eventthe purpose of installing, maintaining, and operating such pipelines, meters, valves, and any other equipment which may be deemed necessary by the Town to extend or improve service for existing or future Applicants, on such fare as are required by the Town. Is alcohol allowed By execution hereof, the Applicant shall guarantee payment of all other rates, fees, and charges due the Town. Liquidation of said Applicant fees shall give rise to be served at the Xxxxx Community Building? Yes, but the renter must comply with all discontinuance of service under the terms and conditions of the Town’s Ordinance. By execution hereof, the Applicant agrees that noncompliance with the terms of this agreement by said Applicant shall constitute denial or discontinuance of service until such time as the violation is corrected to the satisfaction of the Town. Any misrepresentation of the facts by the Applicant on this agreement shall result in discontinuance of service pursuant to the terms and conditions of the Town’s Ordinances. N O T I C E Request for Confidentiality of Personal Information Maintained by the Town of Xxxxxx Utilities Department. Personal information in your Town of Xxxxxx Utilities Department Applicant account records (e.g., name, address, telephone number, or social security number) is generally considered public information under the Texas Government Code, Chapter 552 (Public Information Act). The Texas Utilities Code, Chapter 182 (Rights of Utilities Customers), provides that a government-operated utility may not disclose personal information if the Applicant requests that the government-operated utility keep the personal information confidential. This form enables you to request confidentiality of your personal information under Texas Utilities Code, Chapter 182. If you wish to request confidentiality of your personal information, please check the box below. I request that my personal information maintained by the Town of Xxxxxx Utilities Department be kept confidential under Texas Utilities Code, Chapter 182. I understand that the Town of Xxxxxx Utilities Department may charge each Applicant who requests confidentiality under this subchapter a fee not to exceed the administrative cost of complying with the request of confidentiality. The fee charged by the Town of Xxxxxx Utilities Department for this Service is $ 0.00. (No Charge)  Applicant Signature * A request for confidentiality under Chapter 182 does not prohibit a government operated utility from disclosing personal information in a Applicant’s account record to: (1) an official or employee of the state, a political subdivision of the state, or the United States acting in an official capacity; (2) an employee of a utility acting in connection with the employee’s duties; (3) a consumer reporting agency; (4) a contractor or subcontractor approved by and providing services to the utility, the state, a political subdivision of the state, or the United States; (5) a person for whom the Applicant has contractually waived confidentiality for personal information; or (6) another entity that provides water, wastewater, sewer, gas garbage, electricity, or drainage service for compensation. An Applicant may rescind a request for confidentiality by providing the government-operated utility written permission to disclose personal information. A government-operated utility or an officer or employee of a government-operated utility is immune from civil liability for a violation of Texas Utilities Code, Subchapter B. I have received a copy of the “TOWN OF XXXXXX WATER DEPARTMENT SERVICE AGREEMENT”. I have read this notice and understand the conditions stated. Signature Date TOWN OF XXXXXX WATER AND SEWER LATE FEE & COLLECTION POLICY The Town of Xxxxxx sends a bill for the minimum amount due each month. It is the Applicant’s responsibility to make sure payments are made on time regardless of the delivery method. All payments must be received at Town Hall by the close of business on the due date. The due date is on the 15th day of the month unless the 15th falls on a Friday or Town of Xxxxxx non-workday, payments will be due on the next business day. If you are unsure of the exact due date, please call Town Hall. Any payment placed in the rental contract pertaining drop box after Town Hall business hours will be posted to alcoholyour account the NEXT BUSINESS DAY. How do I purchase insurance naming A $20.00 late fee will be charged for payments made after Town Hall business hours on the City of Xxxxxx as an additional insured for my event that I am serving alcohol at due date. TOWN HALL BUSINESS HOURS: Monday – Thursday 7:30 AM to 5:00 PM Friday 7:30 AM to 11:30 AM Accounts with unpaid balances remaining 10 days after the HCB? One option would due date will be subject to call your homeowners or business insurance company and ask if they could produce disconnect. There is a certificate of insurance naming the City of Xxxxxx as an additional insured in the amount reconnect fee of $1,000,000 for 40.00 and the day of your event at the Xxxxx Community Buildingreconnect can only be done during regular Town Hall business hours. If this option fails, another option would be to purchase insurance through the City of Medina’s insurance company’s tenant user liability insurance program (TULIP)TAMPERING FEES & REGULATIONS: SEE ORDINANCE NO. To get a quote or purchase insurance for your event go to xxx.xxxxxxxxxxxxxxxxxxxxxx.xxx and click on “TULIP (Purchase or Quote)” and enter the facility code: 0501-AZ7. Where do I call if 240 I have more questions?received a copy of the WATER AND SEWER LATE FEES & COLLECTION POLICY FOR THE TOWN OF XXXXXX. I have read this page and understand the conditions stated. Signature Date

For Office Use Only. Total Amount Paid $ Received in Payroll (Date) (By) Submitted to Admin. Asst. (Date) (By) KBI Submitted on (Date) KBI Check # ; Date PdReceived (Date) APS Request Emailed (Date) APS Results Received (Date) CAR Request Emailed (Date) CAR Results Received (Date) DMV Submitted (Date) DMV Results Received (Date) Results: Placed in file Mailed to Consumer Consumer Name DMV Background Check Kansas 3rd Party Consent Form *PLEASE PUT THE INFORMATION EXACTLY AS IT IS ON YOUR LICENSE* I hereby certify that my name is (First Name) (Middle Initial) (Last Name) Address (Street Address) (City) (State) (Zip) Birthdate (MM/DD/YYYY) Telephone Number Driver’s License Number Don’t have one  Issuing Authority (State) I hereby authorize LINK Fiscal Agent to obtain my vehicle registration and/or driver’s license record information including my personal information on those records. Signature (Date) DIRECT DEPOSIT FORM (Direct Deposit is Required) DSW Name: !!! PLEASE PRINT CLEARLY!!! ➢ If you have a bank account, fill out the bank information below: Bank Name: Routing #: _ Checking Acct #: Savings Acct #: (Attach voided blank check) ➢ If you do not have a bank account:  Commerce Direct Check Card (complete form below) $4.95 setup fee will be deducted from first direct deposit. Authorization for Electronic Entries to Commerce Direct Check Card The undersigned hereby authorizes LINK, Inc. (the Employer) to make electronic credit entries and any necessary adjustments involving these entries in the account identified below at Commerce Bank (the Bank) and authorizes the Bank to accept such entries and make any necessary adjustments. It is agreed that these entries will be made under the rules of Guests: Security Deposit*: $ Building Rental Fee: $ Alcohol Rental Fee: $ *The security deposit the National Automated Clearing House Associations. This authorization will remain in effect until written notice of termination is to cover any damage delivered to the facilityEmployer in a timely manner so as to afford the Employer an opportunity to act thereon, violations In no event shall such termination be effective as to entries processed prior of the rental agreement, extra clean-up or cancellation of event without 3 weeks such notice. Payment InstructionsEmployee Information Name \ \ Social Security # Home Phone Cell Phone Date of Birth Mailing Address City, State, Zip Signature: • Deposits and rental fees are payable at booking to reserve the building. • Checks made payable to________________________________________________ Date: City of Xxxxxx. • Any payments made by personal check must be received by the City of Xxxxxx at least three weeks in advance of the event. If received within three weeks of the event, it must be submitted in the form of a cashier’s check or cash. • All checks for rental fees and security deposits are cashed upon receipt, not held. XXXXX COMMUNITY BUILDING Mailing Address: City of Xxxxxx 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 Phone: (000) 000-0000 CITY OF XXXXXX Located: 0000 Xxxx Xxxxx Xxxxxx, XX 00000 Xxxxx Community Building Damage Survey Please inspect the facility prior to your rental date and note any existing damages to the facility to make sure you will not be liable for damages done prior to your event. Circle in red the damaged locations on the layout and describe the damages on the lines below. X X Assembly Room Food Service Area Storage Rooms Bathrooms Ceiling Area Other XXXXX COMMUNITY BUILDING CLEANING CHECKLIST • Empty all garbage cans and recycle bins even if small amount in can o Replace can liners • Wipe all tables with disinfectant soap • Please put all tables and chairs away correctly o Tables like sides together o Chairs as directed on wheeled carts • Vacuum main room carpet and all rugs including front entry o IF CARPET IS WET, PLEASE USE CARPET CLEANER INSTEAD OF VACUUM • Wipe main door glass of handprints and smears • Wipe down food service area (kitchen) with disinfectant spray o Wipe counters, appliances and sink • Sweep and Mop: o Front entry o Men’s restroom o Women’s restroom o Food service area (kitchen) (Mop found in mechanical room behind door with xxx xxxxxx) • Clean Men’s and Women’s restroom o Wipe vanities, sink and faucets o Clean toilets and urinals o Clean mirrors o Empty all waste receptacles in stalls • Before exiting, please put furnace/air thermostat on “Continuous Unoccupied” setting • Leave key under office door Frequently Asked Questions—Xxxxx Community Building How do I rent the Xxxxx Community Building? After checking the online calendar for openings, call Xxxxx Lions representative Xxxxx Xxxxx at 000-000-0000 to confirm availability of your dates. You may then print a contract and special function sheet, fill them out and send them to the City of Xxxxxx with a check for the deposit and rental fees to hold your day. The fee schedule for rental fees and deposits are posted on the website. Who do I make the check payable to? The City of Xxxxxx Can I write out one check for the deposit and the rental fee? Yes, please write one check for the total amount (rental fee + deposit). All security deposit and rental fees made by personal check shall be received by the City of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted in the form of a cashier’s check or cash. All checks for rental fees and security deposits are cashed upon receipt, not held. Where do I send the contract and check? Send to: City of Xxxxxx Attn: Xxxxx Community Building 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 When are the Security Deposit and Rental Fee due? The security deposit and rental fee are due at the time of signing the Rental Agreement. Your rental date will not be guaranteed until the city has received your security deposit, rental fee, and the signed rental agreement. Security deposit and rental fees made by personal check shall be received by the City of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted in the form of a cashier’s check or cash. All checks for rental fees and security deposits are cashed upon receipt, not held. Is the Community Building in Xxxxx or Medina? It is in the community/neighborhood of Xxxxx, but it is in the City of Xxxxxx. What are the directions to the Xxxxx Community Building? The community building is located at 0000 Xxxx Xxxxx, directly behind Farmers State Bank of Xxxxx off of Xxxxx Road. When coming off of Highway 55, turn South on Xxxxx Road or Sioux Drive into Uptown Xxxxx. Who is responsible for setting up the room and cleaning up afterwards? The person or group renting the building is responsible for the building. Please review the cleaning check list attached to your rental agreement. How many tables are available? When renting the Community Building there are fifteen (15) five foot round tables that seat 7-8 people and fifteen (15) eight foot rectangular tables that seat 8-10 people. How many chairs are available? When renting the Community Building there are 120 non-folding chairs and 17 folding chairs available. How do I get a key to the facility for my event? Your key to the Xxxxx Community Building will be given to you by appointment before your event or you will be given the code to the lock box. Call Xxxxx Xxxxx at 000-000-0000 for a convenient time. If I have rented items from elsewhere that are to be picked up, do I need to be there? Yes! You are responsible for the building and its contents when pick ups occur. Please make arrangements with the company for time of pick up. Remember, the Xxxxx Community Building does not have regular open hours so you must let them into the building. How do I get my security deposit back? After your event, a HCB representative will assess the building and check for damage, proper put away and clean up. If all is satisfactory, a check will be sent back to you in the mail. It takes two- three weeks to receive your returned deposit check. If there are inadequacies in the above, the City of Xxxxxx will assign a fee and issue the remaining balance of your deposit check. Remember that you as the renter are responsible for any damage done by contractors or caterers you hire for your event. Is alcohol allowed to be served at the Xxxxx Community Building? Yes, but the renter must comply with all the terms in the rental contract pertaining to alcohol. How do I purchase insurance naming the City of Xxxxxx as an additional insured for my event that I am serving alcohol at the HCB? One option would be to call your homeowners or business insurance company and ask if they could produce a certificate of insurance naming the City of Xxxxxx as an additional insured in the amount of $1,000,000 for the day of your event at the Xxxxx Community Building. If this option fails, another option would be to purchase insurance through the City of Medina’s insurance company’s tenant user liability insurance program (TULIP). To get a quote or purchase insurance for your event go to xxx.xxxxxxxxxxxxxxxxxxxxxx.xxx and click on “TULIP (Purchase or Quote)” and enter the facility code: 0501-AZ7. Where do I call if I have more questions?______________

For Office Use Only. Total Date of rental_______________ Date/Amount Paid $ Check # ; Date Pd: Deposit received_____________/_______ Number of Guests: Security fields___________ Price per field__________________ Balance Due (Rental/Deposit*: $ Building Rental Fee: $ Alcohol Rental Fee: $ *The security deposit ) _________/_________ Received by________________________________ Renter___________________________________ Contact #__________________________________ St. Address_______________________________ City/State/Zip______________________________ Email____________________________________________ Athletic Complex Rules Xxxxx County Parks and Recreation Department will have field(s) as ready as weather permits. Field(s) will be prepared “game ready” once prior to usage. For the use of the field lights for any non-sanctioned Xxxxx County Parks & Recreation event or non league team a $15.00 per hour fee will be required. Please contact the office for use of the lights. This does not apply for tournaments. NO VEHICLES ALLOWED IN NON-DESIGNATED AREAS. Parking in designated areas only. Vehicles not parked in an approved marked space may be ticketed or towed at the owner’s expense. NO ALCOHOLIC BEVERAGES ARE ALLOWED ON THE PROPERTY. If alcohol is discovered, future usage of facility will be permanently revoked. NO DOGS OR PETS OF ANY KIND ALLOWED. NO EXCEPTIONS! Smoking in designated smoking areas only. WCRD Staff person must be notified and must approve tents, sunshades, pop-ups, or any other shelter that requires driving spikes for stabilization before placement, due to cover any possible damage to the facilityirrigation or electrical systems. All trash and debris MUST be placed in receptacles. Complex MUST be policed of trash and debris (including bathrooms) before departure! Each team should clean their dugout at the end of each game and dispose of trash and debris properly! Xxxxx County Parks & Recreation reserves the right to cancel any event due to inclement weather or poor field conditions. In case of poor weather, violations of or field conditions the rental agreement, extra clean-up event will be cancelled and may or cancellation of event without 3 weeks notice. Payment Instructions: • Deposits and rental fees are payable at booking to reserve the building. • Checks made payable to: City of Xxxxxx. • Any payments made by personal check must be received by the City of Xxxxxx at least three weeks in advance of the event. If received within three weeks of the event, it must be submitted in the form of a cashier’s check or cash. • All checks for rental fees and security deposits are cashed upon receipt, not held. XXXXX COMMUNITY BUILDING Mailing Address: City of Xxxxxx 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 Phone: (000) 000-0000 CITY OF XXXXXX Located: 0000 Xxxx Xxxxx Xxxxxx, XX 00000 Xxxxx Community Building Damage Survey Please inspect the facility prior to your rental date and note any existing damages to the facility to make sure you will may not be liable for damages done prior rescheduled. Decisions concerning cancellations due to your eventweather or field conditions and rescheduling events will remain solely with WCRD staff and are not subject to appeal. Circle in red the damaged locations on the layout and describe the damages on the lines below. X X Assembly Room Food Service Area Storage Rooms Bathrooms Ceiling Area Other XXXXX COMMUNITY BUILDING CLEANING CHECKLIST • Empty all garbage cans and recycle bins even if small amount in can o Replace can liners • Wipe all tables with disinfectant soap • Please put all tables and chairs away correctly o Tables like sides together o Chairs as directed on wheeled carts • Vacuum main room carpet and all rugs including front entry o IF CARPET IS WET, PLEASE USE CARPET CLEANER INSTEAD OF VACUUM • Wipe main door glass of handprints and smears • Wipe down food service area (kitchen) with disinfectant spray o Wipe counters, appliances and sink • Sweep and Mop: o Front entry o Men’s restroom o Women’s restroom o Food service area (kitchen) (Mop found in mechanical room behind door with xxx xxxxxx) • Clean Men’s and Women’s restroom o Wipe vanities, sink and faucets o Clean toilets and urinals o Clean mirrors o Empty all waste receptacles in stalls • Before exiting, please put furnace/air thermostat on “Continuous Unoccupied” setting • Leave key under office door Frequently Asked Questions—Xxxxx Community Building How do I rent the Xxxxx Community Building? After checking the online calendar for openings, call Xxxxx Lions representative Xxxxx Xxxxx at 000-000-0000 to confirm availability of your dates. You may then print a contract and special function sheet, fill them out and send them to the City of Xxxxxx with a check for the deposit and rental fees to hold your day. The fee schedule for rental fees and deposits are posted on the website. Who do I make the check payable to? The City of Xxxxxx Can I write out one check for the deposit and the rental fee? Yes, please write one check for the total amount (rental fee + deposit). All security deposit and rental fees made by personal check shall be received by the City of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted in the form of a cashier’s check or cash. All checks for rental fees and security deposits are cashed upon receipt, not held. Where do I send the contract and check? Send to: City of Xxxxxx Attn: Xxxxx Community Building 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 When are the Security Deposit and Rental Fee due? The security deposit and rental fee are due at the time of signing the Rental Agreement. Your rental date will not be guaranteed until the city has received your security deposit, rental fee, and the signed rental agreement. Security deposit and rental fees made by personal check shall be received by the City of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted in the form of a cashier’s check or cash. All checks for rental fees and security deposits are cashed upon receipt, not held. Is the Community Building in Xxxxx or Medina? It is in the community/neighborhood of Xxxxx, but it is in the City of Xxxxxx. What are the directions to the Xxxxx Community Building? The community building is located at 0000 Xxxx Xxxxx, directly behind Farmers State Bank of Xxxxx off of Xxxxx Road. When coming off of Highway 55, turn South on Xxxxx Road or Sioux Drive into Uptown Xxxxx. Who is responsible for setting up the room and cleaning up afterwards? The person or group renting the building is responsible for the buildingNo soft toss hitting against any fence. Please review the cleaning check list attached to your rental agreement. How many tables are available? When renting the Community Building there are fifteen (15) five foot round tables that seat 7-8 people refrain from disturbing players, coaches and fifteen (15) eight foot rectangular tables that seat 8-10 people. How many chairs are available? When renting the Community Building there are 120 non-folding chairs and 17 folding chairs available. How do I get a key to the facility for my event? Your key to the Xxxxx Community Building will be given to you by appointment before your event or you will be given the code to the lock box. Call Xxxxx Xxxxx at 000-000-0000 for a convenient officials during game time. If I have rented items from elsewhere that are to be picked up, do I need to be there? Yes! You are responsible for the building and its contents when pick ups occur. Please make arrangements with the company for time Discharging of pick up. Remember, the Xxxxx Community Building does not have regular open hours so you must let them into the building. How do I get my security deposit back? After your event, a HCB representative will assess the building and check for damage, proper put away and clean up. If all firearms is satisfactory, a check will be sent back to you in the mail. It takes two- three weeks to receive your returned deposit check. If there are inadequacies in the above, the City of Xxxxxx will assign a fee and issue the remaining balance of your deposit check. Remember that you as the renter are responsible for any damage done by contractors or caterers you hire for your event. Is alcohol allowed to be served at the Xxxxx Community Building? Yes, but the renter must comply with all the terms in the rental contract pertaining to alcohol. How do I purchase insurance naming the City of Xxxxxx as an additional insured for my event that I am serving alcohol at the HCB? One option would be to call your homeowners or business insurance company and ask if they could produce a certificate of insurance naming the City of Xxxxxx as an additional insured in the amount of $1,000,000 for the day of your event at the Xxxxx Community Building. If this option fails, another option would be to purchase insurance through the City of Medina’s insurance company’s tenant user liability insurance program (TULIP). To get a quote or purchase insurance for your event go to xxx.xxxxxxxxxxxxxxxxxxxxxx.xxx and click on “TULIP (Purchase or Quote)” and enter the facility code: 0501-AZ7. Where do I call if I have more questions?prohibited.

For Office Use Only. Total Amount Paid $ Pre-event inspection completed? Date: _____ Post-event inspection completed? Date: Renter Present: Y / N Reservation/Cleaning/Damage Deposit received? Y / N Check # ; Date Pd: Number Rental Fees received? Y / N Check # Date Cleaning/Damage/Cancellation Fee assessed? Y / N Date Please attach copy of Guests: Security Deposit*: $ Building Rental Fee: $ Alcohol Rental Fee: $ *The security letter to renter advising that deposit is forfeited. Net funds refunded back to cover any damage Renter: Check # Date Rental Complete Y / N Assigned Facility Rental Manager’s Signature DVAC Community Room Rental Client Orientation Checklist When meeting with the rental client for the pre­visit inspection, please remember the following items: ○ Event parking should all be in front of the building, if the crowd is larger we can arrange for cones blocking entrances to the facilitymember responce parking area ○ Evening events may have the outside parking lights illuminated (light switch is by the wheelchair ramp by the elevator on the middle floor) ○ The coffee pot in the kitchen may be used, violations explain its use (turn it on 30­45 minutes before needing to make coffee) ○ DO NOT USE COFFEE POT AND MICROWAVE AT THE SAME TIME. ○ The rental swipe pass is hanging in the closet closest to the door to the garage in the community room, when rental is complete the key should be left in the kitchen in front of the coffee pot (turned to the off position) ○ The thermostat is currently uncovered until Xxx finds a new cover to replace the broken one, it should be turned up 2 hours before the event to no higher than 68 and turned down to 60 at the end of the event ○ The tables and chairs should all be put away at the end of the event ~ chairs no higher than 7 in a pile ~ tables rolled out to the carriage holder in the ante room ○ Nothing may be attached/affixed to the wall ○ Tables should be rolled or carried in the community room, never dragged ○ The front door may be blocked open with the white duct tape, the tape MUST be removed at the end of the event ○ NO VISITORS ARE ALLOWED TO ENTER THE GARAGE OR BASEMENT AREA. ○ Minors are to be supervised at all times. ○ Restrooms have motion sensitive lights and should have their trash emptied by DVAC before the event and by the rental agreement, extra clean-up or cancellation of client after the event without 3 weeks notice. Payment Instructions: • Deposits and rental fees are payable at booking to reserve the building. • Checks made payable to: City of Xxxxxx. • Any payments made by personal check ○ All event trash must be received by removed and taken to the City dumpster in the back when complete ○ Any messes on the floors of Xxxxxx at least three weeks the kitchen or community room must be swept and mopped to return floor to condition found (bring the mop from the garage to the handicapped area for ease in advance access ○ Any problems during the event, provide officers list ○ Alcohol service is only allowed with the insurance rider and is limited to beer and wine only ○ Refrigerator and freezer may be used but need to be cleared of items before end of the event. If received within three weeks of the event, it must be submitted in the form of a cashier’s check or cash. • All checks for rental fees and security deposits are cashed upon receipt, not held. XXXXX COMMUNITY BUILDING Mailing Address: City of Xxxxxx 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 Phone: (000) 000-0000 CITY OF XXXXXX Located: 0000 Xxxx Xxxxx Xxxxxx, XX 00000 Xxxxx Community Building Damage Survey Please inspect the facility prior to your rental date and note any existing damages to the facility to make sure you will not be liable for damages done prior to your event. Circle in red the damaged locations on the layout and describe the damages on the lines below. X X Assembly Room Food Service Area Storage Rooms Bathrooms Ceiling Area Other XXXXX COMMUNITY BUILDING CLEANING CHECKLIST • Empty all garbage cans and recycle bins even if small amount in can o Replace can liners • Wipe all tables with disinfectant soap • Please put all tables and chairs away correctly o Tables like sides together o Chairs as directed on wheeled carts • Vacuum main room carpet and all rugs including front entry o IF CARPET IS WET, PLEASE USE CARPET CLEANER INSTEAD OF VACUUM • Wipe main door glass of handprints and smears • Wipe down food service area (kitchen) with disinfectant spray o Wipe counters, appliances and sink • Sweep and Mop: o Front entry o Men’s restroom o Women’s restroom o Food service area (kitchen) (Mop found in mechanical room behind door with xxx xxxxxx) • Clean Men’s and Women’s restroom o Wipe vanities, sink and faucets o Clean toilets and urinals o Clean mirrors o Empty all waste receptacles in stalls • Before exiting, please put furnace/air thermostat on “Continuous Unoccupied” setting • Leave key under office door Frequently Asked Questions—Xxxxx Community Building How do I rent the Xxxxx Community Building? After checking the online calendar for openings, call Xxxxx Lions representative Xxxxx Xxxxx at 000-000-0000 to confirm availability of your dates. You may then print a contract and special function sheet, fill them out and send them to the City of Xxxxxx with a check for the deposit and rental fees to hold your day. The fee schedule for rental fees and deposits are posted on the website. Who do I make the check payable to? The City of Xxxxxx Can I write out one check for the deposit and the rental fee? Yes, please write one check for the total amount (rental fee + deposit). All security deposit and rental fees made by personal check shall be received by the City of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted in the form of a cashier’s check or cash. All checks for rental fees and security deposits are cashed upon receipt, not held. Where do I send the contract and check? Send to: City of Xxxxxx Attn: Xxxxx Community Building 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 When are the Security Deposit and Rental Fee due? The security deposit and rental fee are due at the time of signing the Rental Agreement. Your rental date will not be guaranteed until the city has received your security deposit, rental fee, and the signed rental agreement. Security deposit and rental fees made by personal check shall be received by the City of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted in the form of a cashier’s check or cash. All checks for rental fees and security deposits are cashed upon receipt, not held. Is the Community Building in Xxxxx or Medina? It is in the community/neighborhood of Xxxxx, but it is in the City of Xxxxxx. What are the directions to the Xxxxx Community Building? The community building is located at 0000 Xxxx Xxxxx, directly behind Farmers State Bank of Xxxxx off of Xxxxx Road. When coming off of Highway 55, turn South on Xxxxx Road or Sioux Drive into Uptown Xxxxx. Who is responsible for setting up the room and cleaning up afterwards? The person or group renting the building is responsible for the building. Please review the cleaning check list attached to your rental agreement. How many tables are available? When renting the Community Building there are fifteen (15) five foot round tables that seat 7-8 people and fifteen (15) eight foot rectangular tables that seat 8-10 people. How many chairs are available? When renting the Community Building there are 120 non-folding chairs and 17 folding chairs available. How do I get a key to the facility for my event? Your key to the Xxxxx Community Building will be given to you by appointment before your event or you will be given the code to the lock box. Call Xxxxx Xxxxx at 000-000-0000 for a convenient time. If I have rented items from elsewhere that are to be picked up, do I need to be there? Yes! You are responsible for the building and its contents when pick ups occur. Please make arrangements with the company for time of pick up. Remember, the Xxxxx Community Building does not have regular open hours so you must let them into the building. How do I get my security deposit back? After your event, a HCB representative will assess the building and check for damage, proper put away and clean up. If all is satisfactory, a check will be sent back to you in the mail. It takes two- three weeks to receive your returned deposit check. If there are inadequacies in the above, the City of Xxxxxx will assign a fee and issue the remaining balance of your deposit check. Remember that you as the renter are responsible for any damage done by contractors or caterers you hire for your event. Is alcohol allowed to be served at the Xxxxx Community Building? Yes, but the renter must comply with all the terms in the rental contract pertaining to alcohol. How do I purchase insurance naming the City of Xxxxxx as an additional insured for my event that I am serving alcohol at the HCB? One option would be to call your homeowners or business insurance company and ask if they could produce a certificate of insurance naming the City of Xxxxxx as an additional insured in the amount of $1,000,000 for the day of your event at the Xxxxx Community Building. If this option fails, another option would be to purchase insurance through the City of Medina’s insurance company’s tenant user liability insurance program (TULIP). To get a quote or purchase insurance for your event go to xxx.xxxxxxxxxxxxxxxxxxxxxx.xxx and click on “TULIP (Purchase or Quote)” and enter the facility code: 0501-AZ7. Where do I call if I have more questions?

For Office Use Only. Total Amount Paid $ Check # ; Date PdAge at Admission: Number Membership Type: Membership #: YMCA Program/Classroom: Director’s Signature: Date: 2017-2018 Transportation Plan My child will arrive at the program with a parent or his/her designee and will depart from the program with a parent or his/her designee. Teachers will ask for a photo identification card until they become familiar with person(s) picking up. THE COMMONWEALTH OF MASSACHUSETTS Department of GuestsEarly Education and Care Small Group and Large Group Transportation Plan and Authorization CHILD’S NAME: Security DepositDOB: CHILD’S NAME: DOB: CHILD’S NAME: DOB: CHILD’S NAME: DOB: My child will be attending the following days and times: Day Arrive Depart Monday am/pm am/pm Tuesday am/pm am/pm Wednesday am/pm am/pm Thursday am/pm am/pm Friday am/pm am/pm MY CHILD WILL ARRIVE AT THE PROGRAM: MY CHILD WILL DEPART FROM THE PROGRAM: PARENT/DESIGNEE DROP OFF PARENT/DESIGNEE PICK UP PUBLIC or PRIVATE SCHOOL PUBLIC or PRIVATE SCHOOL *: $ Building Rental Fee: $ Alcohol Rental Fee: $ PRIVATE TRANS. ARRANGED BY PARENT *PRIVATE TRANS. ARRANGED BY PARENT *Please provide name of company, phone #, and copy of agreement PARENT /GUARDIAN SIGNATURE DATE REFER TO FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM FOR RELEASE INFORMATION Must be updated annually or if parent makes any changes regarding the transportation to and from the center or if their schedule changes. Parent Statement of Understanding The security deposit following information is important for the safety and protection of your child. Please read the information and sign this form to cover acknowledge your receipt and understanding off the Merrimack Valley YMCA’s procedures governing the safety of children in our programs. I understand that YMCA staff and volunteers are not allowed to babysit or transport program participants any damage to the facility, violations time outside of the rental agreement, extra clean-up or cancellation of event without 3 weeks noticeYMCA program. Payment Instructions: • Deposits and rental fees are payable at booking to reserve the building. • Checks made payable to: City of Xxxxxx. • Any payments made by personal check must Immediate disciplinary action will be received taken by the City YMCA toward staff and volunteers if a violation is discovered. I understand that at no time may a staff person be alone with a single child where they cannot be observed by others. This means no one-on-one supervision of Xxxxxx at least three weeks in advance of the eventchildren. If received within three weeks of the event, it must be submitted in the form of a cashier’s check or cash. • All checks for rental fees and security deposits are cashed upon receipt, not held. XXXXX COMMUNITY BUILDING Mailing Address: City of Xxxxxx 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 Phone: (000) 000-0000 CITY OF XXXXXX Located: 0000 Xxxx Xxxxx Xxxxxx, XX 00000 Xxxxx Community Building Damage Survey Please inspect the facility prior to your rental date and note any existing damages to the facility to make sure you I understand that my child will not be liable allowed to leave a licensed program with an unauthorized person. Any person authorized to pick up your child must either be listed with the YMCA or other arrangements must be made by calling the YMCA office to inform them of a change. Persons who pick up your child must have a photo ID to verify identity. I understand that should a person arrive to pick up my child who appears to be under the influence of drugs or alcohol, for damages done prior the child’s safety, staff may have no recourse but to your eventcontact the police. Circle Please do not put staff in red a position where they have to make this judgment call. I understand that the damaged locations on YMCA prohibits inappropriate talk, jokes, or sharing details of one’s personal life and any kind of harassment in the layout presence of children, parents, and describe members. I understand that the damages on the lines below. X X Assembly Room Food Service Area Storage Rooms Bathrooms Ceiling Area Other XXXXX COMMUNITY BUILDING CLEANING CHECKLIST • Empty all garbage cans and recycle bins even if small amount in can o Replace can liners • Wipe all tables with disinfectant soap • Please put all tables and chairs away correctly o Tables like sides together o Chairs as directed on wheeled carts • Vacuum main room carpet and all rugs including front entry o IF CARPET IS WETYMCA is mandated, PLEASE USE CARPET CLEANER INSTEAD OF VACUUM • Wipe main door glass by state law, to report any suspected cases of handprints and smears • Wipe down food service area (kitchen) with disinfectant spray o Wipe counters, appliances and sink • Sweep and Mop: o Front entry o Men’s restroom o Women’s restroom o Food service area (kitchen) (Mop found in mechanical room behind door with xxx xxxxxx) • Clean Men’s and Women’s restroom o Wipe vanities, sink and faucets o Clean toilets and urinals o Clean mirrors o Empty all waste receptacles in stalls • Before exiting, please put furnace/air thermostat on “Continuous Unoccupied” setting • Leave key under office door Frequently Asked Questions—Xxxxx Community Building How do I rent the Xxxxx Community Building? After checking the online calendar for openings, call Xxxxx Lions representative Xxxxx Xxxxx at 000-000-0000 to confirm availability of your dates. You may then print a contract and special function sheet, fill them out and send them child abuse or neglect to the City appropriate authorities for investigation. I have read and understand the statements above and have received a copy of Xxxxxx with the Pre School Child Care Parent Handbook. Parent / Guardian Signature Date Parent Handbook Sign OFF/RELEASE FORM I have received a check copy of the Parent Handbook, Health Care Policy and Holiday Closure Listing for the deposit and rental fees to hold your dayYear. The fee schedule for rental fees and deposits are posted on the website. Who do I make the check payable to? The City of Xxxxxx Can I write out one check Parent Handbook Health Care Policy Holiday Closure Listing for the deposit and the rental fee? Yes, please write one check for the total amount (rental fee + deposit). All security deposit and rental fees made by personal check shall be received by the City Year Code of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted in the form of a cashier’s check or cash. All checks for rental fees and security deposits are cashed upon receipt, not held. Where do I send the contract and check? Send toConduct Parent Signature: City of Xxxxxx Attn: Xxxxx Community Building 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 When are the Security Deposit and Rental Fee due? The security deposit and rental fee are due at the time of signing the Rental Agreement. Your rental date will not be guaranteed until the city has received your security deposit, rental fee, and the signed rental agreement. Security deposit and rental fees made by personal check shall be received by the City of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted in the form of a cashier’s check or cash. All checks for rental fees and security deposits are cashed upon receipt, not held. Is the Community Building in Xxxxx or Medina? It is in the community/neighborhood of Xxxxx, but it is in the City of Xxxxxx. What are the directions to the Xxxxx Community Building? The community building is located at 0000 Xxxx Xxxxx, directly behind Farmers State Bank of Xxxxx off of Xxxxx Road. When coming off of Highway 55, turn South on Xxxxx Road or Sioux Drive into Uptown Xxxxx. Who is responsible for setting up the room and cleaning up afterwards? The person or group renting the building is responsible for the building. Please review the cleaning check list attached to your rental agreement. How many tables are available? When renting the Community Building there are fifteen (15) five foot round tables that seat 7-8 people and fifteen (15) eight foot rectangular tables that seat 8-10 people. How many chairs are available? When renting the Community Building there are 120 non-folding chairs and 17 folding chairs available. How do I get a key to the facility for my event? Your key to the Xxxxx Community Building will be given to you by appointment before your event or you will be given the code to the lock box. Call Xxxxx Xxxxx at 000-000-0000 for a convenient time. If I have rented items from elsewhere that are to be picked up, do I need to be there? Yes! You are responsible for the building and its contents when pick ups occur. Please make arrangements with the company for time of pick up. Remember, the Xxxxx Community Building does not have regular open hours so you must let them into the building. How do I get my security deposit back? After your event, a HCB representative will assess the building and check for damage, proper put away and clean up. If all is satisfactory, a check will be sent back to you in the mail. It takes two- three weeks to receive your returned deposit check. If there are inadequacies in the above, the City of Xxxxxx will assign a fee and issue the remaining balance of your deposit check. Remember that you as the renter are responsible for any damage done by contractors or caterers you hire for your event. Is alcohol allowed to be served at the Xxxxx Community Building? Yes, but the renter must comply with all the terms in the rental contract pertaining to alcohol. How do I purchase insurance naming the City of Xxxxxx as an additional insured for my event that I am serving alcohol at the HCB? One option would be to call your homeowners or business insurance company and ask if they could produce a certificate of insurance naming the City of Xxxxxx as an additional insured in the amount of $1,000,000 for the day of your event at the Xxxxx Community Building. If this option fails, another option would be to purchase insurance through the City of Medina’s insurance company’s tenant user liability insurance program (TULIP). To get a quote or purchase insurance for your event go to xxx.xxxxxxxxxxxxxxxxxxxxxx.xxx and click on “TULIP (Purchase or Quote)” and enter the facility code: 0501-AZ7. Where do I call if I have more questions?Date:

For Office Use Only. Total Amount Paid $ Check # ; Date Pd: Number of Guests: Security Deposit*: $ Building Rental Fee: $ Alcohol Rental Fee: $ *The security deposit is to cover any damage to the facility, violations of the rental agreement, extra clean-up or cancellation of event without 3 weeks notice. Payment Instructions: •  Deposits and rental fees are payable at booking to reserve the building. •  Checks made payable to: City of Xxxxxx. •  Any payments made by personal check must be received by the City of Xxxxxx at least three weeks in advance of the event. If received within three weeks of the event, it must be submitted in the form of a cashier’s check or cash. •  All checks for rental fees and security deposits are cashed upon receipt, not held. XXXXX COMMUNITY BUILDING Xxxxx Community Building Mailing Address: City of Xxxxxx 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 Phone: (000) 000-0000 CITY OF XXXXXX City of Xxxxxx Located: 0000 Xxxx Xxxxx Xxxxxx, XX 00000 Xxxxx Community Building Damage Survey Please inspect the facility prior to your rental date and note any existing damages to the facility to make sure you will not be liable for damages done prior to your event. Circle in red the damaged locations on the layout and describe the damages on the lines below. X X Assembly Room Food Service Area Storage Rooms Bathrooms Ceiling Area Other XXXXX COMMUNITY BUILDING CLEANING CHECKLIST •  Empty all garbage cans and recycle bins even if small amount in can o Replace can liners •  Wipe all tables with disinfectant soap •  Please put all tables and chairs away correctly o Tables like sides together o Chairs as directed on wheeled carts •  Vacuum main room carpet and all rugs including front entry o IF CARPET IS WET, PLEASE USE CARPET CLEANER INSTEAD OF VACUUM •  Wipe main door glass of handprints and smears •  Wipe down food service area (kitchen) with disinfectant spray o Wipe counters, appliances and sink •  Sweep and Mop: o Front entry o Men’s restroom o Women’s restroom o Food service area (kitchen) (Mop found in mechanical room behind door with xxx xxxxxxmop bucket) •  Clean Men’s and Women’s restroom o Wipe vanities, sink and faucets o Clean toilets and urinals o Clean mirrors o Empty all waste receptacles in stalls •  Before exiting, please put furnace/air thermostat on “Continuous Unoccupied” setting •  Leave key under office door Frequently Asked Questions—Xxxxx Community Building How do I rent the Xxxxx Community Building? After checking the online calendar for openings, call Xxxxx Lions representative Xxxxx Xxxxx at 000763-000458-0000 1838 to confirm availability of your dates. You may then print a contract and special function sheet, fill them out and send them to the City of Xxxxxx with a check for the deposit and rental fees to hold your day. The fee schedule for rental fees and deposits are posted on the website. Who do I make the check payable to? The City of Xxxxxx Can I write out one check for the deposit and the rental fee? Yes, please write one check for the total amount (rental fee + deposit). All security deposit and rental fees made by personal check shall be received by the City of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted in the form of a cashier’s check or cash. All checks for rental fees and security deposits are cashed upon receipt, not held. Where do I send the contract and check? Send to: City of Xxxxxx Attn: Xxxxx Community Building 0000 Xxxxxx Xxxx 00 Xxxxxx, XX 00000 MN 55340 When are the Security Deposit and Rental Fee due? The security deposit and rental fee are due at the time of signing the Rental Agreement. Your rental date will not be guaranteed until the city has received your security deposit, rental fee, and the signed rental agreement. Security deposit and rental fees made by personal check shall be received by the City of Xxxxxx at least three weeks in advance of the event. Security deposit and rental fees received by the City of Xxxxxx within three weeks of the event must be submitted in the form of a cashier’s check or cash. All checks for rental fees and security deposits are cashed upon receipt, not held. Is the Community Building in Xxxxx or Medina? It is in the community/neighborhood of Xxxxx, but it is in the City of Xxxxxx. What are the directions to the Xxxxx Community Building? The community building is located at 0000 Xxxx Xxxxx, directly behind Farmers State Bank of Xxxxx off of Xxxxx Road. When coming off of Highway 55, turn South on Xxxxx Road or Sioux Drive into Uptown Xxxxx. Who is responsible for setting up the room and cleaning up afterwards? The person or group renting the building is responsible for the building. Please review the cleaning check list attached to your rental agreement. How many tables are available? When renting the Community Building there are fifteen (15) five foot round tables that seat 7-8 people and fifteen (15) eight foot rectangular tables that seat 8-10 people. How many chairs are available? When renting the Community Building there are 120 non-folding chairs and 17 folding chairs available. How do I get a key to the facility for my event? Your key to the Xxxxx Community Building will be given to you by appointment before your event or you will be given the code to the lock box. Call Xxxxx Xxxxx at 000-000-0000 for a convenient time. If I have rented items from elsewhere that are to be picked up, do I need to be there? Yes! You are responsible for the building and its contents when pick ups occur. Please make arrangements with the company for time of pick up. Remember, the Xxxxx Community Building does not have regular open hours so you must let them into the building. How do I get my security deposit back? After your event, a HCB representative will assess the building and check for damage, proper put away and clean up. If all is satisfactory, a check will be sent back to you in the mail. It takes two- three weeks to receive your returned deposit check. If there are inadequacies in the above, the City of Xxxxxx will assign a fee and issue the remaining balance of your deposit check. Remember that you as the renter are responsible for any damage done by contractors or caterers you hire for your event. Is alcohol allowed to be served at the Xxxxx Community Building? Yes, but the renter must comply with all the terms in the rental contract pertaining to alcohol. How do I purchase insurance naming the City of Xxxxxx as an additional insured for my event that I am serving alcohol at the HCB? One option would be to call your homeowners or business insurance company and ask if they could produce a certificate of insurance naming the City of Xxxxxx as an additional insured in the amount of $1,000,000 for the day of your event at the Xxxxx Community Building. If this option fails, another option would be to purchase insurance through the City of Medina’s insurance company’s tenant user liability insurance program (TULIP). To get a quote or purchase insurance for your event go to xxx.xxxxxxxxxxxxxxxxxxxxxx.xxx and click on “TULIP (Purchase or Quote)” and enter the facility code: 0501-AZ7. Where do I call if I have more questions?