NATIVE AMERICAN STUDENT AND COMMUNITY CENTER
Reservation Form
(PLEASE PRINT LEGIBLY)
Preparer Information
This is the primary contact for the event
Dept/Organization ______________________________________ Contact Name ________________________________
Phone _______________________ Fax ______________________ Email ______________________________________
Address ___________________________
City _________________
State ____
Zip Code ____________
Payment PSU Index Code ______________
Check ____________________________
Cash _______________
Event Information
Title of Event ______________________________________________________________________________________
Purpose of Event ___________________________________________________________________________________
Date(s) ___________________________________________________________________________________________
Number of Attendees Expected: ____________
Start Time
_________ am/pm
End Time
_________ am/pm
Room(s) Requested
Room, Room Number, and size
Gathering Area, 110, 2770 sq. ft.
Gallery/Lounge, 104, 1654 sq. ft.
Classroom, 170, 507 sq. ft.
Computer Room, 160, 510 sq. ft.
Conference Room, 180, 477 sq. ft.
Rooftop Garden
Kitchen, 111, 311 sq. ft.
Set-up
Seated meal, round tables
Seated meal, traditional tables
Lecture seating
Stand-up reception
Stand-up reception
Seated at tables
Standard Set-up
Standard Set-up
Standard Set-up
Basic
Full
Capacity
84
140
160
200
80
30
10
24
104
Availability
Not available for leasing during regular hours of operation
Special Arrangements can be made
Not available for leasing
Deposit required
Deposit required
110 (Gathering Area) 170 (Classroom)
180 (Conference room) Please circle the room number
Will you be serving food? (circle)
Yes
No
IF YES: PSU Catering __ check if using PSU Catering Outside Caterer ________________________________ Food Waiver attach
Will you require Kitchen use? (circle) Yes
No
Do you have a food handler’s card? (circle)
Yes
No
IF NO: Will you or someone in your group have one before the date of the event? Yes No Please Circle one
IF NO: We cannot lease the kitchen to your organization.
NOTE: WE ARE REQUIRED BY LAW TO HAVE ALL FOOD HANDLER’S CARDS POSTED IN THE NASCC KITCHEN. FOOD HANDLER CARDS MUST BE ON
FILE WITH THE NASCC SPECIALIST BEFORE THE DATE OF THE EVENT, OR ACCESS TO THE KITCHEN WILL BE DENIED
Service and Equipment Needed for the Event
If nothing is needed, please write: “No services needed.” _____________________________________
Please check all that apply
o
o
o
o
Registration Table #
needed______
Refreshment Table #
needed______
Lectern
Portable CD Player
o
o
o
o
Telephone w/ Active Line
TV, VCR/DVD Cart
Easel # needed______
Flip Chart & Pad # needed
______
o
o
o
o
o
Over Head Projector #
needed ______
Digital Projector w/ Screen
Screen
Microphone
Hospitality
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NATIVE AMERICAN STUDENT AND COMMUNITY CENTER
Room 110 Set-Up Instructions
Number of Tables:
Rectangles _______
Rounds _______
Number of Chairs: ______
Will you require a partition?
Yes
No please circle one
Please attach a sketch and description of the room diagram can be found at www.pdx.edu/nativecenter under leasing forms, Room 110 sketch
Set-Up Time:
Break-Down Time:
15 Minutes
15 Minutes
30 Minutes
30 Minutes
1 Hour Other ___________ please mark one
1 Hour Other ___________ please mark one
Other Charges that may Apply Before or During the Event
o Photocopies: $0.10/page
o Local Faxes: $0.75/page
o Reserved Parking (per space): $14
o Refundable Basic-Kitchen Deposit: $150
o
o
o
o
Refundable Full-Kitchen Deposit: $250
Condition of Facility Fine: $200
Campus Watch Student per hour: $15
Public Safety Officer per hour: $35
I have read and agree to the rules and provisions detailed in the NASCC Policy and Procedures. I agree to submit any
necessary forms, payments, or information required by NASCC and PSU. I understand that: failure to do so may result in
cancellation or additional fees; my completed copy of this form does not represent a confirmed reservation; and I will
notify NASCC staff within 48 hours of any changes in the above information or I may incur additional fees.
________________________________________
Signature
____________
Date
_______________________________________________PLEASE DO NOT MARK BELOW THIS POINT_______________________________________________
o
Full
FOR NASCC STAFF USE ONLY
o Internal
o
CCU
Receiver ________________________________
Date Received _______________
NASCC Specialist Approval _____________________________________________
Rental Cost $___________
Auxiliary Cost $___________ Total Cost $___________
Revisions/Cancelations
Date ___________
Specific Changes _______________________________________
Rental Cost $___________
Auxiliary Cost $___________ Total Cost $___________
Date ___________
Specific Changes _______________________________________
Rental Cost $___________
Auxiliary Cost $___________ Total Cost $___________
Date ___________
Specific Changes _______________________________________
Rental Cost $___________
Auxiliary Cost $___________ Total Cost $___________
Date ___________
Specific Changes _______________________________________
Rental Cost $___________
Auxiliary Cost $___________ Total Cost $___________
o
o
o
o
Food Waiver
Room Sketch
CCU Application _____________ authorization initials
Co-Sponsorship Application
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