University Room Reservation Form Please fill out the following information in order to schedule a room/space on campus. We will follow up with you within five (5) business days after you have submitted this form.
	Name* First Name Last Name
	UM-Dearborn Email*
	Phone Number*
	Name of Student Organization*

	Event/Program Information
	Title of Event*
	Number of Attendees*
	Description of Event/Planned Activities*
	Is this event being co-sponsored?* Yes No
	Are you charging admission, registration fees or collecting donations?* Yes No If yes, there will be a room charge.
	Are you selling any items or services, or conducting a fundraiser?* Yes No If yes, there will be a room charge.
	Will you invite or are you planning to have off-campus attendees?* Yes No
	Who will be your off-campus attendees?*
	Will your event involve music, singing or amplified sound?* Yes No
	Will your event need audio/visual support?* Yes No
	Indicate any and all AV equipment needed for your event.* Hand held microphone Sound Cord VGA Cable LCD projector VCR/DVD player Other: Other Value
	Do you plan to have food and/or beverages at your event?* Yes No

	Dates and Times Please note:  Requests MUST be at least 5 (five) business days prior to your event/meeting.  Requests under the 5 business day allowance will be DENIED.
	Start Date/Time Requested* Month   Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year   2012 2013     Hour   01 02 03 04 05 06 07 08 09 10 11 12 Minute :   00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59   AM/PM   AM PM Must be at least 5 business days from event start date.
	End Date/Time Requested* Month   Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year   2012 2013     Hour   01 02 03 04 05 06 07 08 09 10 11 12 Minute :   00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59   AM/PM   AM PM
	Is this a repeating event? Yes No
	If yes, how often will it repeat? Weekly Bi-Weekly Monthly Other
	Building(s) Preferred* University Center CASL Fairlane Center SSB ELB Other: Other Value Please indicate which buildings you would like to have your event in. The UC will automatically be the first priority for scheduling.
	Rooms(s) Preferred in the UC* Kochoff Hall A Kochoff Hall B Kochoff Hall C All three sections of Kochoff Hall 1225 (seats 36) 1227 (seats 24) 2190 (seats 8) Patio Stage Other: Other Value Please indicate which rooms you would like to have your event in.
	Rooms(s) Preferred in the Fairlane Center* Quad E Dining Room D Room 180 Classroom Space Other: Other Value Please indicate which rooms you would like to have your event in.
	Floor Plan* Conference Square (Default) "U" shape Classroom Lecture Dining Tables Open (no tables or chairs) Other: Other Value
	What other information should we know about your event?

	Billing Information
	Project/grant number*

	Conditions and Liabilities
	I agree to abide by the University Center policies. For liability purposes, I agree to ensure that members and guests of the sponsoring organization will not move or tamper with any furnishings or equipment, including tables and chairs. I further understand that all facilities and equipment are subject to availability. I will be responsible for submitting any necessary forms or information to the UC Administrative Office by the dates specified on my Room Confirmation and understand that failure to do so may result in cancellation or charges to my reservation. I understand that my copy of this completed form does not represent a confirmed reservation. Misrepresentation of the nature of the activity, or failure to fully disclose pertinent details regarding this event, may result in additional charges or denial of future facility use. Yes
	I understand that this room/table cannot be used by off-campus vendors/individuals under this reservation. I also certify that the information contained on this form is correct. Yes
	I understand that it is the responsibility of the organization to restore the room(s) to the original condition or a clean-up fee will be assessed. Yes