Treasure State Baptist Associati

Treasure State Baptist Association

ROCKWALL APPLICATION

2010

Date of Application: ________________

Name of Church: ________________________________________________________

Pastor: ________________________________________________________________

Mailing Address: ________________________________________________________

City: ________________________________ State: ______ Zip: ________________

Requested Date of Use:

First Choice: From ________________ To ________________

Second Choice: From ________________ To ________________

Purpose of Use: _________________________________________________________

Name and Positions of Program Personalities: ________________________________________________________________________________________________________________________________________________

Person Responsible for the Rockwall:

Name ____________________________________ Position ___________________

Address ______________________________________________________________

City ________________________________ State ______ Zip _________________

Phone: Office __________________ Home _________________ Cell _____________

I have enclosed my certificate of insurance q

I have been to the appropriate training for the Rock Wall q

We, the undersigned, make application for scheduling the use of the rockwall with the assurance that we assume responsibility for complying with the guidelines and for use of the rockwall..

Pastor’s Signature _________________________________________ Date _________

Signature of Person Responsible for trailer _______________________ Date _________

A $100 fee MUST accompany this application. Make check payable to Treasure State Baptist Association.

OFFICE USE ONLY

Date received: _____________

Fee Received _____________

Schedule & Guidelines sent __