Request for Revocable Permit

Instructions: This form is used to collect information necessary for the Department of Campus Life to prepare a revocable permit for the use of facilities in accordance with SUNY’s Use of Facilities by Non-Commercial Organizations Policy.

Legal Name of the Organization

Legal Address of the Organization

Street address, City, State and Zip Code

Contract Contact Information

Name and Title

Contract Contact Address

Contract Signatory Information

Name and Title

Description of Planned use of Facilities ("Activity")

Will Children/Youth Under 17 be Participating in the Activity?

Yes

Requested Facility Location

Requested Facility Room Number (if applicable)

Date and time access ends

Date and time that permittee will access the facility (e.g. M-F, 8-5 p.m.)

Please describe any services that the permittee will need in order to use the facility for its intended purpose

If providing services for the campus community, please provide a detailed description of the services

Name of person completing this form