Form 41 - Facility Use

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Facility Use Form 41
Circle Facility Requested: Conference Center / Station 82 Conference Room / Station 83 Training Tower
Reservation Date(s): _________________________________________________________________
Time Frame of Event: _______________________________________________________________________________
*Note this time frame includes your set up time, event time, and clean up time.
Number of Guests: ____________________________________
Does an additional fee apply?
Yes / No
*There is an additional $380 fee for events with alcohol.
*There is an additional $130 fee for weddings & birthdays without alcohol.
If applicable, explain the nature under which alcohol will be served: __________________________________________
__________________________________________________________________________________________________
If you are requesting to use the Station 83 Training Tower, does your agency carry one million dollar per occurrence
commercial liability insurance?
Yes / No / Not Applicable
Meeting Type / Course: ________________________________________________________________________________
Organization: ______________________________________________________________________________________
Circle Type of Group: Government Agency / Personal / NonProfit Corporation registered with State of WA / Profit
Is your group within Lake Stevens?
Yes / No
Contact Info for responsible individual. Name: _____________________________________________________________
Phone:
Email:
___________________________________________
___________________________________________________________
The undersigned acknowledges that they have received and read a copy of the District’s Use and Rental of District’s
Facilities Policy 140 and agrees to be bound by the terms and conditions contained in the policy. Additional charges will
apply if facility is not left in a clean fashion or if Station 82 Conference Room event info is changed from original request.
The undersigned agrees to hold the District harmless from all damages of every kind and nature, including costs and attorney
fees incurred by the District, that may be claimed or accrue by reason of any accident in or on the premises resulting from
the undersigned’s use or occupation of the premises or caused by the acts or negligence of the undersigned or any agent or
invitee of the undersigned.
_________________________________________
_________________________________________
Applicant Signature
Applicant Printed Name
Email Facility Use Form to:
Or Mail to: Lake Stevens Fire / Attn: Facility Rental, 1825 South Lake Stevens Road, Lake Stevens, WA 98258.
Certificate of Insurance/Alcohol Permit should be sent to Lake Stevens Fire / Attn: Facility Rental.
Event reservation will be confirmed once the completed Facility Use Form and payment (if required) are received.
Checks should be made payable to “Lake Stevens Fire”.
The following information is required ONLY if you are renting the Conference Center. Additional charges will not be placed
on your credit card unless the Conference Center is left in an unclean fashion as determined by the District employee responsible
for facility maintenance. This information will be kept confidential and secure, and shredded after the event takes place.
Type of Payment Card: American Express / Master Card / Visa / Discovery
Expiration Date on Card: ____________
Name on Payment Card (please print): ___________________________________________________________________
Full Number on Front of Card: ____________________________________ Last 3 Digits on Back of Card: __________
Billing Address: _____________________________________________________________________________________

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