Room Rental Request Form

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GIAC
Room Rental REQUEST
318 N. Albany St.
Ithaca, NY 14850
Phone 607-272-3622/ Fax 607-272-0250
If have read the GIAC room rental acknowledgement statement and the GIAC
room rental information sheet. My signature below confirms that I have read,
understand and agree to the rental terms and conditions.
Organization/person requesting rental space
Name ________________________________________
Address ______________________________________
City/ State _____________________________________
Phone # ____________ Cell # ___________ Fax # ____________
Event Date _________________ Time ______________
Room(s) requested _______________ Approximate # in group ________
* Please provide a brief description of what the room(s) requested will be used for:
__________________________________________________________
__________________________________________________________
_________________________________________________________
_________________________________________________________
# of tables requested ________ # of chairs requested
__________________
Signature _______________________________ Date __________
Office Use ONLY!
Amount due _____
Payment: Cash ______ Check Amount _____ Check # _____
Date Paid _______
Rev. 1/10

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