The person completing this form and whose signature appears on the form must be over 18 years of age.
Applicant Name
Organisation / ABN
Postal Address
Phone Number / Business / A/H / Mobile
Email Address
Hire Category
(select one) / ☐ Community Group: Not for profit or self-help group that receives little or no funding to run the group or program. This is inclusive of groups deemed to be providing services and activities to our local community.
☐ Community Benefit: Organised activity or service provided by an individual, private business, religious entity or Government agency where there is demonstrated community benefit. Not for profit organisations that receive funding to provide a service. Fundraising event by a not for profit organisation or individual.
☐ Private/Commercial: Organised activity or service provided by an individual, group or organisation where the purpose of the hire is to generate profit or to conduct a private function including, but not limited to, corporate meetings or celebrations.
Public Liability Insurance / ☐ I have a current policy / ☐ I wish to purchase Council’s cover
2. Booking Details
Activity / Event
Hire Type / ☐ Casual / ☐ Regular
Hire Date/s & Times / Day & Date: / Access Time / Event Start
Event Finish / Exit Time
Day & Date / Access Time / Event Start
Event Finish / Exit Time
Day & Date / Access Time / Event Start
Event Finish / Exit Time
Regular Bookings / ☐ Weekly / ☐ Fortnightly / ☐ Monthly / ☐ School Terms / ☐ Full Year
Last date for current year: / First date for following year:
Venue / ☐ Bannockburn Cultural Centre
27 High Street, 5220 7260 / ☐ Bannockburn Family Services Centre
2a Pope Street, 5220 7230
☐ The Well – Smythesdale Business, Health & Community Hub
19 Heales Street, 5321 1500 / ☐ Northern Community Centre, Haddon
396 Sago Hill Road, 5342 7000
Area required (some areas not available at all Centres) / ☐ Small Consulting Room / ☐ Medium Meeting Room (8-12 people)
☐ Large Meeting Room (12-30 people) / ☐ Hall (Bannockburn Cultural Centre only)
(100-120 cabaret or 150 theatre)
☐ Kitchen / ☐ Foyer / ☐ Courtyard
Anticipated Attendees
3. Hire Checklist
☐ / I have contacted the Centre Coordinator to confirm availability of the venue and discussed furniture and equipment requirements.
☐ / I have completed all applicable sections of the Venue Hire Application Form.
☐ / I have contacted the relevant bodies to discuss license requirements for the provision of food and alcohol and have attached relevant documentation to this application (where applicable).
☐ / I have attached a copy of public liability insurance documents or an application form to purchase cover under Golden Plains Shire Council’s casual hirer’s public liability scheme.
☐ / I have arranged a date and time with the Centre Coordinator to collect access card, key or fob and to discuss access, security, emergency and OHS procedures.
☐ / I will ensure that no persons under the age of 18 years will be left unsupervised in the venue.
☐ / I have read and understood my responsibilities under the conditions of hire and information contained within associated forms relating to my hire.
I acknowledge having read the ‘Conditions of Hire’ and undertake to comply with all aspects of such conditions
Name
Signature / Date
Privacy - The Golden Plains Shire considers that the responsible handling of personal information is a key aspect of democratic governance, and is strongly committed to protecting an individual’s right to privacy. Council will comply with the Information Privacy Principles as set out in the Privacy and Data Protection Act 2014. Council has in place a standard operating procedure that sets out the requirements for the management and handling of personal information.
If you have any queries regarding this Privacy Statement, please contact the Privacy Officer on (03) 5220 7111.
Please return completed form in person to the venue of hire or a Golden Plains Shire Customer Service Centre
or email: ▪ post: PO Box 111, Bannockburn 3331 ▪ fax: (03) 5220 7100
Room Allocated / Public Liability Paid on
Hire Rate / Bond Paid on
Key/Fob Issue Date / Key No. / Bond Returned on
Key/Fob Return Date / Fob No. / Casual Hire Prepaid on
Hire Approved by Golden Plains Shire Authorised Officer on
Name / Signature
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