Request for Use of PIA Building – 2005

PLEASE PRINT:
Name of Organization (where applicable): __________________________________________________________

Name or Type of Event:  _________________________________________________________________________

Date of Usage:  ___________________________________Setup time:  _______ Date:_________________       

Time frame of the event _________________ “Cleaned-up walk around” Date & Time: _______________

Hall Usage Fees:

Main Hall                                                                                        200.00

                        Kitchen facilities?   If Yes, add $ 100.00 per 24hr.                     ________  _____________ 
                                                                                                                          Starting date

Do you want lawn mowed within 3 days of your event? If yes, add $ 50.00      ________ 

                                                                                                                            $  __________ TOTAL Fee Due

Print Contact Person’s Name: ________________________________   Phone #: _____________________

On Island                                                             Off Island (where applicable)                                                                                           

Address: ____________________________________                  ____________________________________

              ____________________________________                   ____________________________________

Phone #: (____)___________________                                         (_____)_______________________

                 area code                                                                 area code

E-mail Address:  _____________________________________________

I have read the Guidelines for PIA Building Usage – 2005, _______________________
                                                                                        Signature of Contact Person

Return forms with a check for $ 100.00 and a self addressed stamped envelope.

Make check out to P. I. A., and send to:

Rosemary Marmaras           PO Box 111            Prudence Island, RI 02872

DO NOT WRITE BELOW, TO BE FILLED OUT BY THE PIA EVENT COORDINATOR

_______________________________                    _____________________________________________

Signature of the P.I.A. Event Coordinator         Name/ phone # of person scheduled for “cleaned-up walk”

The balance of the fee is due 60 days before the event.

___________________________               _______________   #________________
Signature request for renter deposit return    Date returned       Check # of deposit return

A copy of the request form, signed by the Event Coordinator, will verify that your reservation has been made.

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