Forms 91-8693-91-8694-Application For Use Of Judiciary Facilities Form
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3FORM: 91-86-93
THE JUDICIARY
[Rev: 11/2009]
STATE OF HAWAI‘I
APPLICATION FOR USE OF JUDICIARY FACILITIES
Date: ________________________
Applicant: ________________________________________________________________________________
Number of
Organization: _______________________________________________ Participants: __________________
Address: ___________________________________________________ Telephone: ___________________
The use of the following Facility:________________________________________________________
(BUILDING AND ROOM NUMBER)
is requested for ________________________________________ from: ________________________
(DATE)
(TIME)
for the purpose of ____________________________________________________________________
I, the undersigned, on behalf of the organization I represent, will be responsible for the proper care of the
buildings, equipment, and facilities; the payment of the charges as shown below, assessed in accordance
with the Judiciary policies and procedures; and complying with the conditions of use of this Judiciary
facility. I further agree that all laws and Judiciary policies, including those that relate to fire regulations,
alcoholic beverages, etc., will be complied with. I understand that arrangements for security coverage and
payment for services must be made by me and that the name of the individual hired to provide security will
be submitted at least two days prior to the scheduled event.
Applicant’s Signature: ________________________________________ Date: __________________
FOR OFFICIAL USE ONLY:
USER CHARGE(S): $ _______________________
FOR:
ESTIMATE:
ACTUAL:
(Made payable to: STATE DIRECTOR OF FINANCE)
Received Check#: ____________________________
Custodial Services:
$ ____________ $ ____________
Utilities:
$ ____________ $ ____________
❑
❑
INSURANCE REQUIRED:
YES
NO
Others:
$ ____________ $ ____________
❑
❑
SECURITY SERVICES REQUIRED
YES
NO
*SECURITY SERVICES: $ ____________ $ ____________
(TWO sheriffs start at MINIMUM TWO HOURS / cost: $30.00 per hour
per sheriff = $60.00 each)
(THREE (3) or MORE SHERIFFS REQUIRED FOR 25 OR MORE)
RECOMMENDED ACTION:
ACTION:
❑
❑
APPROVED
APPROVED
❑
❑
APPROVED with the following revision(s)
DISAPPROVED
____________________________________________
____________________________________________
____________________________________________
❑
DISAPPROVED
___________________________________________________
__________________________________________________
DIVISION HEAD
DATE
ADMINISTRATIVE DIRECTOR TO THE COURTS
DATE
* To be determined and charged by Sheriff’s Division
Reprographics (07/10)
APPLICATION FOR USE OF JUDICIARY FACILITIES 1D-P1303
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