Leafletting/Demonstration Request

Name of group/organization
Contact Person
First Last
Address of organization/individual
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Email
Type of request (Leafleting, Speech Demonstration)
Date(s) of event/activity
MM slash DD slash YYYY
Time of Event (From)

: Hours

Minutes

AM/PM
Time of Event (To)

: Hours

Minutes

AM/PM
Table/chair request (#)
Please allow at least a five-day lead time.
I, the undersigned, have read, understand and agree to abide by the policy for students, staff and nonaffiliated individuals and groups for Leafleting, Free Speech and Demonstrations as they relate to Board Policy #4620 Student Demonstrations.
Name
First Last
Date
MM slash DD slash YYYY