Form
District
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Antelope Valley
Bill Hart
Campo de Cahuenga
Crescent Bay
Reyes Adobe
Outreach
Non-District (Council)
Unit Type
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Pack
Troop
Crew
Ship
Post
Non-Unit (District or Council)
Unit Number
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Description of Activity (i.e. Blue & Gold, Court of Honor, etc.)
*
Date of Activity Start
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Month
-
Day
Year
Date
Date of Activity End
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Month
-
Day
Year
Date
Full Facility Information (Name of Facility, full address, facility contact person and their information)
*
NAME OF CERTIFICATE HOLDER AND ADDRESS: (THIS WILL BE THE NAME AND ADDRESS ON THECERTIFICATE, BE SURE TO INCLUDE BOARD MEMBERS, AGENCIES, OR COUNTIES, IF REQUESTED.(EXAMPLE: LA COUNTY DEPT OF PARKS AND RECREATION.)
*
Has the facility requested an additional insured?
*
Yes
No
Has the facility requested an endorsement?
*
Yes
No
Amount requested
$1 Million
$2 Million
Estimated # of people attending
Fees charged by the facility
If you received specific requirements from the facility, you may attach a copy here
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