APPLICATION FOR CITIZENS CENTER BUILDING

LOCATED AT 8076 KINGS HIGHWAY

KING GEORGE COUNTY DEPARTMENT OF PARKS & RECREATION

P.O. BOX 71 KING GEORGE, VIRGINIA 22485

Phone Number: 540-775-4386 Website:

1. Name of person/group requesting use of facility:

2. Date requested for use:

CHECK ANY CATEGORIES THAT MAY APPLY

Rappahannock Area Agency on Aging activity

Activity sponsored by King George County Public Schools

Non-profit, civic or charitable organizations serving King George County**

Non-admission fee activity sponsored by a non-profit, non-charitable social group within King

George County (AARP, Virginia Cooperative, Health Department, Social Services, etc.)

King George County government agency

Private parties (wedding receptions, anniversaries, birthdays, etc.) for residents of King George

County

Other/non-resident, please specify

**TAX EXEMPT NUMBER MANDATORY FOR 25% OF RENTAL:

3. Area of the facility requested:

Main Hall Meeting Room Volleyball courts

½ of Main Hall Kitchen

4. Time facility will be used:

(MUST include, minimally, one hour for set-up)(Hours: 8:00a.m - 12 midnight weekends; 8:00a.m - 10 pm weekdays; earlier hours are subject to availability)

5. Describe intended use:

6. Approximate number of persons attending: ; if your real day-of numbers exceed the numbers provided above, you may lose your damage deposit.

7. Will decorations be used?

(NO decorations are to be attached to ceiling tiles, no glitter or confetti. Any decorations used should NOT be attached with duct tape or any other highly adhesive material; and no candles )

8. Will any alcoholic beverages be on the premises?

(If so, please read the following information. If said group plans on having alcoholic beverages they are required to apply for a Banquet (one day) license. Virginia ABC Department (804) 213-4577 or (804) 213-4524. The ABC License will be displayed by Department personnel and in proximity of where the alcohol will be served. The ABC application is available upon request. The Department of Parks and Recreation must have the ABC license in its possession by the Friday prior to the scheduled event.

9. Date the Citizens Center was last used by this group:

NO ACTIVITY WILL BE ALLOWED TO CONTINUE PAST THE HOUR OF 12:00 a.m MIDNIGHT.

Rev.3/2016

IT IS UNDERSTOOD THAT I / WE SHALL COMPLY WITH THE OPERATING GUIDELINES FOR USE OF THE CITIZENS CENTER BUILDING.

Signature of ApplicantDate of Signature

______

Applicants complete mailing addressPhone number (Home & Work)

Email (please print legibly): ______

Please initial (if applicable): ABC Addendum ______Use Restrictions Addendum ______

PARKS & RECREATION OFFICE USE ONLY

Applicable Fee Breakdown:

Damage Deposit: ______Date Received: ______

Basic Rent: ______Date Received: ______

*Cleaning Fee: ______Date Received: ______

Additional Hours ( x $27 per hour): ______

Additional Applicable Fees: ______Description: ______

Total Due: ______

  • Cleaning fee due two weeks prior to scheduled event

Damage Deposit: Amt. Paid: ______Payment type: ______Receipt #: ______

Basic Rent: Amt. Paid: ______Payment type:______Receipt #:______

Cleaning Fee: Amt. Paid: ______Payment type: ______Receipt #: ______

______

Signature King George Parks & Recreation StaffDate of Signature

Application: Approved: ______Denied: ______

Confirmation letter sent: ______Date: ______

ADDITIONAL COMMUNICATIONS WITH RENTER

DATE COMMENTS / REQUESTS / CHANGES