Name of Hiring Organisation:

Expected Use:

Responsible Officer:

Address:

Phone:     

Mobile:

Security Number: (Please choose a four digit number)

Booking Dates:

All hirers, are to have a Public Liability insurance policy in force for the duration of the hire period. This policy shall be for no less than $10,000,000. A copy of the policy must be provided to the Kempsey Shire Council for retention on file. A tax invoice will not be sufficient, as it does not advise of the currency of the policy.

A copy of the Public Liability Insurance policy covering $10,000,000 is appended to the
      printed copy of this application.

A copy of Public Liability Insurance policy covering $10,000,000 will be submitted to
      Council at a later date.

I, agree and on behalf of _____________________________________ (hiring organisation)

have read, understand and agree with the ‘Conditions for Facility Use’ as set down by the Kempsey Shire Council in consideration of the hiring of the facility for the above period and agree to abide by the requirements of this agreement.

_________________________________________                       _____________________
Signature of the Responsible Hiring Officer                                                     Date

_________________________________________                      _____________________
Signature of the Authorised Council Representative                                        Date

Please print form and submit.

The printed form will need to be signed by the applicant and faxed to 6566 3225 with a copy of the public liability insurance before confirmation of the booking from Kempsey Shire Council is received.