Requesting Individual (name, address, phone number)

Requesting Department

Detailed Description of Proposed Activity:

Description of Requested Location:

Age and Number of Expected Participants:

Anticipated safety measures/protection from secondary effects of tobacco use:

Applicant

Date

CONCUR:

Print Name:

Director, Physical Plant Administration

Date

Print Name

Environmental Health & Safety

Date

Office APPROVED:

Vice Chancellor – Finance & Administration

Date