Council Facility Certificate of Insurance Request Form

2. Name of Recreation Council:*

3. Dates and Times of Event:*
   Dates and Times of Event: Start Date

   Dates and Times of Event: Start Time

   —

   Dates and Times of Event: End Date

   Dates and Times of Event: End Time

5. Location(s):*

7. Description of Event or Activity:*

9. Name of Certificate Holder:*

11. Attach Document

    Attach either a Rental Agreement or Rental Application. Failure to provide it with the initial request will only delay the process

13. Contact Name:*

14. Phone:*

15. Email Address:

Leave This Blank:


17. 1. Receive an email copy of this form.
18. Email address

    This field is not part of the form submission.

19. Submit Submit and Print

* indicates a required field