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Company Name*

First name*

Last name*

Phone Number*

Email*

Street Address*

City*

State*

Zip Code*

Campus Location*

Name of Event*

Estimated Attendance Size?*

Start Date*

Month/Day/Year

Start Time*

Set Up Time Needed (minutes)*

Take Down Time Needed (minutes)*

Additional Dates Needed?

Description of Event*

Technology Needs*

Microphone

Projector/Screen

Computer/Network Access

IT Support for Special Set Up

Additional Comments*

Certificate of Liability

Required by Yavapai College is a minimum $1,000,000 Certificate of Liability Insurance with Yavapai College, 1100 E. Sheldon Street, AZ 86301 as the Certificate Holder.