NameofOrganization: NonProfitNo. Date:
InvoiceAddress:
Meets2weeksnotification
Doesnotmeet2weeksnotification
NameofPersonResponsibleforInvoice: ResidencePhone: Cell Phone: BusinessPhone:
EmailAddress: Besttimetobereached:
Date(s)ofEvent:
HoursofUse (starttime/endtime): ExpectedAttendance:
PurposeofEvent:
Room/FacilityRequested:
FeesfortheActivity: willbecharged 
willnotbe
charged
Iffeescollected,amountcharged:$
Description Hour(s) Day(s) HourlyorDailyRate
$
$
$
$
$
$
$
Makecheckpayableto:UniversityofHawaiiatHilo
200WestKawiliStreet
Hilo,Hawaii96720
TOTALCHARGES:
$
BEFORESigning:IhavereadtheAgreementforFacility Useandunderstandandagreetoabidebyalltherulesandregulationsasstated in the
policy.
Signature(PersonResponsibleforInvoice): AuthorizedPosition: Date:
Universityaffiliatedorregisteredorganization
NonUniversityaffiliatedorganization
Copyofinsurancepolicyattached
WrittenwaiverforinsurancecoveragefromUniversityofHawaiiatHilo,Chancellor’sOfficeattached
FacilitiesRequestApproved FacilitiesRequestDisapproved
ReasonRequestDenied:
_____________________________________________________________________________________________
Distribution:ApplicantCustodialSecurity Bld
g&Grounds Other:__________________________
REQUESTANDAGREEMENTFORUSEOFUNIVERSITYFACILITIES
ATTACHMENT C
Revised 1/17