Rental Form
Organization _______________________________________________Address ___________________________________________________
City __________ State _______________ Zip ____________________
Phone _______________________ Email ________________________
Fax _________________________
Contact Person _____________________________________________
Applicant is: For-Profit Corporation Partnership 501(c)(3) Nonprofit Corporation Individual
Proposed Performance ____________________________________________
Opening Act ______________________________________ Intermission? yes no
| Date Requests | Purpose | Theatre Use Times | Show Times |
| / / | performance rehearsal | from to | from to |
| / / | performance rehearsal | from to | from to |
| / / | performance rehearsal | from to | from to |
| / / | performance rehearsal | from to | from to |
| / / | performance rehearsal | from to | from to |
| Ticket Prices | Seating Location | Discounts (If any) |
| Price 1 $ | _______________________________ | Senior Citizens $ |
| Price 2 $ | _______________________________ | Students $ |
| Price 3 $ | _______________________________ | Groups (specify min. size) $ |
| Price 4 $ | _______________________________ | Other (please explain) $ |
Hold from sale: On Sale Date:
| Proposed Activities In Addition To Performance | ||
| Pre-performance reception | Post-performance reception | Raffle |
| Merchandise Sales | "Playbill" Distribution | |
| Poster / banner display | Backstage food service | |
Submission of an application does not grant or imply an agreement to use the Count Basie Theatre. Only when a License Agreement has been fully executed is an agreement in place. Applicant acknowledges that application will be reviewed and that additional information, documentation or references may be requested. When and if this application is approved, Count Basie Theatre will hold the date(s) approved for up to fourteen (14) days, at which time if applicant has not confirmed the dates, the dates may automatically be released. If another party should inquire about dates before applicant has confirmed dates, applicant shall have forty-eight hours from such notification by Count Basie Theatre to confirm or release dates.
Signature _______________________________________________ Date __________
Count Basie Theatre Use: Approved and holding Date Not Approved ___________ Initials