GENERAL BUILDING and EQUIPMENT USE FORM

Louisa Baptist Church

P.O. Box 552

Louisa, VA 23093

(540) 967-1364

Organization Name: ________________________ Date of Application: ____________

Contact Name: ____________________________ Phone Number: _______________

Contact Address: ________________________________________________________

Check which item best describes your group:

_______ Non-Profit Organization ______ Religious Group

_______ Member of Louisa Baptist Church ______ Profit Organization

_______ Other: ______________________

Facility or Equipment Requested: ___________________________________________

Date(s) Requested: _______________________Time Requested: ________ to _______

Number of people involved: ___________

Brief explanation of your request: ____________________________________________

________________________________________________________________________________________________________________________________________________

________________________________________________________________________

List any equipment or materials that will be brought onto the church grounds: _________

Please return form with deposit to the church office at your earliest convenience as your reservation can be confirmed only upon receipt of the above information and deposit.

We agree to comply with the rules and regulations of the Louisa Baptist Church, as outlined in the Guidelines for Use of Church Property.

___________________________ __________

Signature Date

__________________________ ___ ___________ For Church Use:

Signature of Approval from Date Total Fee Required ____________

Building and Use Committee Sound Technician ____________