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APPLICATION FOR FACILITY USAGE CITY OF FARMINGTON DEPARTMENT OF PARKS, RECREATION & CULTURAL AFFAIRS Please Note: A separate application must be submitted per request type. Upon approval, a facility permit receipt will be issued. Please do not do any promotion of this request until you have received confirmation. This form is not for Picnic Permit requests or fields not within the control of the City of Farmington PRCA Department. A separate permit process is required for such reservations. REQUEST TYPE: *Practice *Game Camp/Clinic Fundraiser Special Function REQUEST MADE BY: (Name of Organization/School/Individual) CONTACT PERSON: FACILITY OR FIELDS TO BE USED: PROPOSED ACTIVITY: BEGINNING DATE: ENDING DATE: DAYS & TIMES Check days and specify times (A.M. or lights, concessions, or other requests. LIABILITY COVERAGE PROVIDED BY: (CO. NAME) (POLICY#) (EXP.DATE) Applicant Name Title Email Address Telephone No. Street Address City State Zip I agree that while using the City Of Farmington fields, courts, and facilities for the purpose described in this request that we will not discriminate on the basis of disability. Applicant Signature Date For further information and to return form, contact: PRCA Administration Office 901 Fairgrounds Rd. Farmington, NM 87401 Office: (505) 599-1401 Fax: (505) 599-1185 Weekday Start Time End Time Lights Concessions Other Sunday Monday Tuesday Wednesday Thursday Friday Saturday OFFICE USE ONLY Date received: Time received: Approved/ Not Approved