Lebanon-Laclede County Library

Date Submitted:                 Date Needed:

Start Time / End Time:

Group or Organization Name:

Room Desired:    Joan True Rm.,   Dan True Rm. ,    Dan & Joan True Rms. ,    
Computer Rm. ,     Benage Rm.

Number Expected to Attend:

Purpose / Function of the Organization:     

Responsible Person(s):        

Address:

Phone:            E-Mail Address:

Group / Organization Member Other Than Applicant:                                

Phone:

Person Paying for Room Rental and/or Deposit (if different than contact person):

Equipment Needed:    Podium,     Television ,    VCR  ,    Screen ,   
Laptop & Projector

Room Setup: Tables, how many?      Chairs, how many? 

Will food be provided?:  (Fees may apply)                          Yes        No
         If yes, by whom    
Will event be open to the public?:                                        Yes        No
Will registration / Admission charges be required?:             Yes        No
Is admission limited to members of the organization?:        Yes        No
Will media be invited?:                                                       Yes        No
Will directional signage be posted?:                                    Yes        No
Permission to put on public calendar?:                                Yes        No

Can the names and phone numbers listed on this form be released to library patrons that have inquiries
regarding the meeting?     Yes         No

I have read the policies governing the use of the Library rooms and equipment and agree to comply with them.
The Library is not responsible for accidents, damage or loss of personal items while in the reserved room. By agreeing to this document you agree you are releasing the Library of any resposibility.

Agrees      Disagrees      Name of Applicant:                           

Signature: _____________________________________________________

Room setup: Table(s) , how many?              Chairs, how many?    

  Yes, I would like for the library staff to setup for the $25 fee        
  No,  I will setup and teardown the chairs and tables myself with no fee.

If you want the Library staff to setup chairs, or tables and chairs, there is a $25.00 fee. Please
call 417-532-2148 ahead of time and indicate how you would like the room arranged.

 Or, print out the completed form and mail to:
Lebanon-Laclede County Library
915 S Jefferson
Lebanon, MO  65536,  OR  Fax to 417-532-7424,

For Staff Use Only

Application Approved By: ________________________________________

Deposit: $_____________              Date Paid:_____________________

Room Rental Fee: $__________

Equipment Fee:    $__________

Total:                     $__________

Payment Received:______________________      Cash _____      Check _____

Received From:__________________________________