312309 06/13/17 CITY OF CARMEL, INDIANA VENDOR: 357599
"< CHECK AMOUNT: $**.....100.00`
ONE CIVIC SQUARE AMERICAN CANCER SOCIETY
s rte; CARMEL, INDIANA 46032 CENTRAL INDIANA AREA SERVICES CHECK NUMBER: 312309
+ 6030 W 62ND ST CHECK DATE: 06/13/17
�4ow io INDIANAPOLIS IN 46278
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 GAZEBO 100.00 OTHER EXPENSES
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Nancy Heck if tX 10 -1
Lt.Jeff Horner v - _ :p-�
CITY OF CARMEL Adam Harrington O/l-Ag_4-3D-,I&
FACILITY USE REQUEST FORM
Name/Organization:
Point of Contact: �'r►Y�cul -M yo
Address:
City, State, Zip: ����S V - I Z 1�' �l 2� 100
Home Phone: al)31�� 1�J3� Cell Phone: ((034 3qu
Email Address: T 1'G�G(/� ® � Fax Number ( )
For Profit Organization: Non-Profit Organization: _Individual:
�U o2-O/ `7- ?J
Day and Date Requested: V YUI )
Time Requested: 01 a.m./p.m. to: (�a.m./p.m. (This includes set-up and clean-up time.)
Rehearsal Date: Time: a.m./p.m. to a.m./p.m.
City Facility Requested: Gazebo Fountain Area Japanese Garden
Palladium Center Green Caucus Room (1/3)_(2/3)_Council Chambers
Special Requests: Electricityp� Fountain Restroom X Other
Purpose: IACD ar L)�Q C V � Number of People Expected: ?j
Vendors: Yes)0 No_(See Item 5, City of Carmel Facility Use Policy attached)
City Street Closing: (See Item 9, City of Carmel Facility Use Policy attached)
Large or Race Events:
Neighborhood Street Closing (Street(s), Address(es) Blocked)
The Carmel Board of Public Works and Safety reserves the right, in its sole discretion, to deny
any facility use request and/or revoke any previously granted request to use a City facility for
any lawful reason.
Received this 4 day of v v ,201 40
Mayor's Office
Revised: 04/16/2011