NORTHLAND COMMUNITY AND TECHNICAL COLLEGEFACILITY USE INTAKE FORM FOR EXTERNAL ORGANIZATIONS
Select a location:
__TRF CAMPUS
__EGF CAMPUS
__AEROSPACE SITE
__ROSEAU SITE
Date: __________ Organization Name: __________________________________________________
Select an Organization Type:
 _____For Profit – Requires Certificate of Insurance Facilities Use Agreement
 _____Non Profit – Requires Certificate of Insurance & Facilities Use Agreement
 _____Government Agency – Provide State Statue # & Government Facilities Use Agreement
Title of Event: _______________________________________________________________
Type of Activity/ Discription: ___________________________________________________
Mailing Address_____________________________________________________________
City/State/Zip_______________________________________________________________
Contact Name __________________________________
Telephone__________________
Email Address: _________________________________
Fax: ______________________
Type of room(s) requested (Specify room number if known) ___________________________
____________________________________________________________________________
Date(s) needed ________________________
Day
Date
Yr.
Time of meeting: _________ to ____________
Set up/Tear down time: ___________________
Number expected to attend ____________________ Internet Connection Needed ___________
Special Equipment/Set up requirements ____________________________________________
____________________________________________________________________________
____________________________________________________________________________
Return form to: Colleen Kukowski, Northland Community and Technical College, 2202 Central Ave NE,
East Grand Forks, MN 56721; Phone (218) 793-2407; FAX: (218) 793-2805; Email:
colleen.kukowski@northlandcollege.edu
NCTC Space Requires:
 Facilities Use Agreement – Colleen will fill out with the information you provided & send to you
 Certificate of Insurance – Organization Provides to Colleen
Room Fee (Will be based on Tier Rate): _________hours @ _______ per hour/ Half Day/ Full Day
*Tier 1 – Non Profit
*Tier 2 – For Profit
* Government Agency
Other Charges May Apply: Facilities: $75 per/person, per/hour
IT: $75
Weekend: additional $75
Application Received
Facilities Use Agreement Sent/Res. #
Returned for signature
Fully signed
Copy mailed
Proof of Insurance
CC #
Amount
Payment Received
Invoice #
Event Cancelled
116083
Contract due by: