This form must be submitted at least 3 weeks prior to requested use date

This form is to be submitted when facilities at the University of Washington, Bothell are requested for non-curricular use. The purpose of the activity(s), seminar, conference and/or event must conform to the UWB mission, to general policy outlined in WAC 478-136, and to UWB policy on use of UWB facilities. If you are unfamiliar with the content of the WAC or UWB policy, please read about them at http://www.uwb.edu/admin/services/fuac/policy.xhtml, prior to completing this form.

Requests for facilities use associated with curricular events should be submitted directly to the UWB Registrars Office (uwbrooms@uwb.edu).

INSTRUCTIONS: Complete all fields with the requested information. Incomplete forms will not be processed and will be returned for correction.

Requestor Information
	Requestor's Name*
	Name of Requesting Organization*
	Type of Organization UW CCC non-UW
	If non-UW, how did you find out about us?*
	Sponsor for activity:* All outside parties must have a UW or CCC sponsor. All student groups and/or departments must have an advisor to sponsor activity.
	Email of Sponsor:
	Billing Address (non-UW) or UW or CCC Department and Box Number*
	Budget Number (UW or CCC)
	Telephone number*
	Fax number
	Email address
Event Information
	Detailed description of Activity, Seminar, Conference or Event (Be specific and complete) (Include any commercial or political activity.)
	Names of participating lecturers, instructors, artists or performers
	Will this event be attended only by faculty, staff or enrolled students of the UW or CCC? Yes No
	Will a registration or admission fee be charged? Yes No
	If yes, state amount and purpose:*
	If your event spans more than one quarter, please submit a form for each quarter (Academic Calendar UWB, Academic Calender CCC) If this is a recurring event, please select 3 definite occurrences of this event: Occurrence 1 Occurrence 2 Occurrence 3 Dates for this event Event Start Time Specify A.M. Or P.M. Event End Time Specify A.M. or P.M. Building Requested (North Creek Events Center*, UW1, UW2, etc) Room # or Area of Grounds Requested (Specify room #, vista, promenade, parking garage, etc) Estimated Attendance Set-up/tear-down time desired (Indicate time)
*For events held at the North Creek Events Center Please put LB2 for the Building Requested
	Special Request Items Indicate any of the following items that may apply to the conference or event. An appointment or telephone conversation with the Facilities Use coordinator to provide specific information is required before the request will be considered for approval. Additional fees may be assessed for these requirements:
	Sample room/area configuration: Lecture Workshop Banquet Conference Seminar Reception Open space: food event table(s) and chairs Custom Custom layout (you must fax or mail a drawing to the Events Manager)
	Additional chairs, tables, staging, electrical, podium, special equipment, etc. required
	Please specify:
	Campus Media Center equipment (e.g. sound system, computer, projector) or services required.
	Event will occur, in whole or in part, after normal working hours (8am - 5pm) or on a weekend.
	Food and/or beverages will be served. (Name and phone no. of caterer)
	If you plan to serve alcohol, you must complete the Banquet Permit. (Alcohol/Banquet Permit)
	Public Safety Services to be billed to event organizer or budget#.
	I have read the policy on Use of University Facilities and my organization meets all of the requirements stated therein. Yes No