Community Room Reservation

Organization Name
Non-Profit
Organization Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact

First NameLast Name
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Acknowledgement of Guidelines for Community Room

Required
I hereby, acknowledge that I have received, read, and understand “Guidelines Regarding Use of Community Room”, that I, on behalf, of the Organization agree to comply with the provision of such and understand that the Organization can be held responsible for, and will pay for, any damages that the members of the Organization may cause to any Benton REA Community Room, and agree to be responsible for any keys/key-cards issued to them by Benton REA and to return such items upon the termination by either party of any Benton REA Community Room reservation or use.
First Name
Last Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Benton REA Community Room Request