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Please return to: Town of Minden 1604 Esmeralda Ave. Suite 101 Minden, NV 89423 Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] X:\common\file cabinet\CVIC Hall\Applications and Rental RM APP 2009.doc 8/23/2013 TOWN OF MINDEN ROOM APPLICATION AND USE PERMIT This application and deposit must be on file in Town of Minden in order to guarantee facility rental. Name of Organization / Contact Person Date(s) of Rental Type of Activity to be conducted Home phone Work phone Email Address Mailing Address City and State Zip Code Physical Address City and State Zip Code Requested opening time Requested closing time Total hours Anticipated number of People Is this event open to the public? Yes No If so, what is the starting time of the event? Will the activity involve alcohol consumption? Yes___ No___ If yes, will alcohol be sold? Yes___ No___ If alcohol is to be sold, a permit must be obtained from the Sheriff's Office. Also please check with Nevada State Health Department for temporary food permit. AVAILABLE AMENITIES: Number of tables requested: Number of chairs requested: Elevator access needed? Yes No Nature and duration of any amplified sound: Other needs/requests: APPLICANT CERTIFIES RECEIVING THE CVIC HALL POLICIES AND PROCEDURES AND AGREES TO ABIDE BY ALL PROVISIONS THEREOF. APPLICANT/RESPONSIBLE PARTY MUST HAVE A COPY OF THIS APPLICATION DURING THE ROOM RENTAL. Policy Received: Signature of applicant Date TO BE FILLED OUT BY OFFICE PERSONNEL ONLY: EXPECTED FEES DUE ACTUAL FEES Amount of Insurance Required: Proof Rec’d: Security Required: Proof Rec’d: (attached) Dep. Rec’d: Check No. Date: QB Credit No. QB Sales No. QB Inv No. Payment Rec’d: Check No. Date: Deposit Returned: QB Credit Refunded