Facilities Request

Complete the form below to request the use of an ASUMH facility for your event.

* Name of Event

* Date(s) of Event

* Start/End Times

* Contact Person Name

* Contact Person Phone

* Email

* # of Participants

* Special Arrangements or Equipment Needed

* Facility Requested (state the specific facility, room, or grounds area you are requesting)

I have reviewed the attached information and agree to abide by the rules and regulations set forth by Arkansas State University – Mountain Home.

This facilities use agreement is made by and between Arkansas State University–Mountain Home, an institution of higher education and agency of the State of Arkansas, located at 1600 S College St, Mountain Home, Arkansas 72653 (“ASUMH”), and the individual stated on this form for the use of any and all requested land, property, buildings, and parking lots owned by ASUMH (individually a “Facility”, plural the “Facilities”).

By checking this box you agree to abide by all rules and conditions set out above and in the ASUMH Facilities Usage Guidelines pages.

* Renter's E Signature

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