Rental Request

Name: Date of Request:

Organization:

Phone Number:

E-mail address:

Date of Desired Rental:

Space Needs: Please check all that apply:

Facilities Use

Amenities Use

Deposit Received: $_______________________________________

Totals w/deposit: $_______________________________________

Commercial Attachments: (circle one) Proof of Insurance – IRS Exemption Letter

Hold Harmless Statement – Other: __________________________

Use and/or rental of USSI facilities are at the sole discretion of USSI and/or Agent.

Applicant Signature: __________________________________ Date: _____________