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APPLICATION FOR FACILITY USAGE CITY OF FARMINGTON DEPARTMENT OF PARKS, RECREATION & CULTURAL AFFAIRS *Upon approval a written permit will be issued. Please do not do any promotion of this request until you have received a confirmation notice. *Does not include Picnic Permits or fields not within the control of the City of Farmington PRCA Department. A separate permit process is required for such reservations. REQUEST MADE BY: (Name of Organization/School/Individual) CONTACT PERSON: FACILITY OR FIELDS TO BE USED: PROPOSED ACTIVITY: BEGINNING DATE: ENDING DATE: SPECIAL INSTRUCTIONS: e.g. concession, field lining, lights, etc Check boxes below: Specify time and circle A.M. or P.M. Sunday A.M./P.M. A.M./P.M. Monday A.M./P.M. A.M./P.M. Tuesday A.M./P.M. A.M./P.M. Wednesday A.M./P.M. A.M./P.M. Thursday A.M./P.M. A.M./P.M. Friday A.M./P.M. A.M./P.M. Saturday A.M./P.M. A.M./P.M. Camp/Clinic Fundraiser Special Function LIABILITY COVERAGE PROVIDED BY: (CO. NAME) (POLICY#) (EXP.DATE) (Applicant) (Title) (Date) (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. For further information and to return form, contact: Farmington Recreation Center 901 Fairgrounds Rd. Farmington, NM 87401 Office: (505) 599-1184 Fax: (505) 325-7079 OFFICE USE ONLY Date received: Time received: Approved/ Not Approved