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APPLICABLE FEES (All fees must be paid at time of application) Contracted Hours: = Staffing Fee: = Set Up / Take Down: Processing Fee: Rental Fee Subtotal: General Liability Insurance (Alcohol): Damage Deposit (Refundable) Total: Tenant: Payments can be made via VISA, MC, Discover, Check, or Money Orders only. Please make checks payable to City of Anaheim. Payments Received: Date: Receipt # Date: Receipt # Tenant: If other expenses occur, charges will be made accordingly. If applicable, deposits are returned 3-4 weeks following the event. SPECIAL CONDITIONS OF AGREEMENT Tenant to provide: (Initial where applicable) Fire Department approved set up diagram and/or applicable permits at least two weeks prior to event: Set up diagram at least two weeks prior to event: Public Dance Permit: General Liability Ins. Certificate & Endorsement, 30 days prior to event: Proof of non-profit status 501(c) 3 Membership Roster (including city residency): Off-duty Anaheim Police Officers for event to be arranged by applicant: Contracted Security Guards, proof required 30 days prior to the event: Copy of Anaheim Business License: Copy of ACS Regulations for Use, initialed & signed by tenant: Copy of ACS Alcohol Regulations signed by tenant: Copy of any promotional materials: Other: Applicant Name: Organization Name: Type of Organization: Address: City: Zip Code: Phone: Alternate Phone: Cell Phone: Fax: Email: Alternate Contact Name: Phone: Alternate Phone: Cell Phone: Fax: Email: ANAHEIM COMMUNITY SERVICES DEPARTMENT APPLICATION FOR ONE-TIME USE OF THE BROOKHURST COMMUNITY CENTER 2271 W. CRESCENT AVE. I ANAHEIM, CA 92801 Phone [PHONE REDACTED] I Fax [PHONE REDACTED] Room(s) Requested: Date of Event: Month: Day: Year: Hours: am/pm to _ am/pm Type of Event: Estimated Attendance: Max. Occupancy: Percentage Anaheim Residents: (Organizations/Businesses) Is the event open to the public? Yes No Will alcohol be served? Yes No Will food be served? Yes No Will event be professionally catered? Yes No Name of catering company: Will any goods or services be sold? Yes No Will event be used as a fundraiser? Yes No If yes, proceeds will be used for EVENT SCHEDULE ALL RENTAL CHANGES MUST OCCUR 30 DAYS PRIOR TO EVENT DATE Set-Up/Preparation Time: am/pm to am/pm Event Time: am/pm to am/pm Alcohol Serving Time: am/pm to am/pm (4 hour maximum) Clean Up Time: am/pm to am/pm Approved Authorized Signature: Date: Denied Reason: Date: TENANT: PLEASE DO NOT WRITE BELOW THIS LINE Rental # Entered by: Date: This form is void until properly filled out and signed by an authorized Community Services Department Representative EQUIPMENT REQUIREMENTS A FLOOR PLAN/DIAGRAM IS REQUIRED FOR ALL SET-UPS Chairs Only: Theatre style to accommodate Chairs & Tables: Classroom style to accommodate______ Chairs & Tables: Banquet style to accommodate Chairs & Tables: Banquet style with Dance Floor to accommodate Number of Card Tables Projection Screen Floor Podium Dry Erase Board VCR/TV U.S.A. Flag California Flag Kitchen Icemaker Warming Ovens