SHIRE OF CHAPMAN VALLEY	PO BOX 1, NABAWA WA 6532	Phone (08) 9920 5011 Fax (08) 9920 5155	Website: www.chapmanvalley.wa.gov.au	ABN 46 173 809 199	Email: cso@chapmanvalley.wa.gov.au

Bill Hemsley Park Community Centre

Venue Hire Application & Permission to Consume Liquor

Applicant: Click or tap here to enter text. Applicant Address: Click or tap here to enter text. Name of Contact: Click or tap here to enter text. Local Contact: Click or tap here to enter text. Phone Number: Click or tap here to enter text.EMAIL: Click or tap here to enter text.

Bill Hemsley Park Community Centre Venue Hire: Date:Click or tap to enter a date. Times: Click or tap here to enter text. to Click or tap here to enter text. Purpose of Function: Click or tap here to enter text.	Estimated Number of People: Click or tap here to enter text.

Facilities required:
Main Meeting Room	Choose an item.	Verandah Included	Choose an item. Kitchen	Choose an item.

CERTIFICATION I hereby certify that I am fully aware of the hire conditions as shown on the attached form. Signature Click or tap here to enter text. Date: Click or tap to enter a date.

BANK DETAILS FOR REFUND OF BOND: ACCOUNT NAME: Click or tap here to enter text. BANK NAME: Click or tap here to enter text. BANK LOCATION: Click or tap here to enter text. BSB: Click or tap here to enter text. ACCOUNT NUMBER: Click or tap here to enter text.

OFFICE USE ONLY Application approved: CEO_____________________________________Date________________ Application NOT approved*_____________________________________Date_______________ Reason *_______________________________________________________________________ HIRE CHARGES: EXEMPT FROM FEES (IE. PART OF THE MANAGEMENT LICENCE) YES	NO BOND:	____________________________	HIRE FEE: ______________________________ AUTHORISED TO BE INVOICED AT THESE FEES & CHARGES __________________________(MFCS)

VENUE HIRE CONDITIONS:

All the venue and bond charges must be paid to the Shire Office before pin number for keys will be issued.

If a key(s) is lost, the relevant lock(s) will have to be renewed and the actual cost of the replacement will be the responsibility of the hirer.

It is the responsibility of the hirer to ensure that the conduct of the persons present at the time of their function behave in an orderly fashion.

It is illegal to consume alcohol on any part of the building and grounds without the prior written approval of the Council. An additional license must be obtained from the Clerk of Courts for the sale of liquor and a copy of license to be provided to council before function.

The cleaning of the facilities used is the responsibility of the hirer. If the premises have been left in an untidy state and Council is required to clean, then the costs involved in such cleaning will be charged to the hirer.

If any items used (e.g. barbeques, etc.) are left in an unsatisfactory condition, the hirer will be requested to carry out the necessary cleaning or repairs to such items to the satisfaction of the Chief Executive Officer and/or Building Officer.

If in the event that any the hirer refuses to undertake the necessary cleaning and/or repairs are required, then Council will carry out the repairs and an appropriate charge specified by the Chief Executive Officer will be forwarded to the hirer.

Ensure all lights are turned off after function. Penalty may be imposed if lights left on.

No spike shoes or boots or the like to be worn in any part of the building except the two main change rooms and public toilets.

Crockery and cutlery hire:

Breakage and losses - the cost of replacement - will be the responsibility of the hirer.

Tables and chairs are not to be removed from the building. All tables and chairs must be stacked in an orderly manner.

Furniture must not be dragged across the floor.

All doors and windows of the building must be closed and locked when vacating.

Authorisation to reimburse bond payment Yes / No (please circle) Inspected Date ____________________ Authorised Officer _________________________