Notification of Event Form

NOTIFICATION OF EVENT

This form is to be used for notification of an event, when no Certificate is required

ASSOCIATION:________________________________
INSURANCE CHAIRMAN:_______________________
CHAIRMAN’S ADDRESS:________________________
CITY/STATE/ZIP: ______________________________

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
TYPE OF FUNCTION - CHECK ONE
______Exhibition Dance _____Club Dance _____Group Travel

Club Name:____________________________________________________
Club Address:___________________________________________________
City: __________________________________________________________
Date of Function: ________________________________________________
Facility being used:_______________________________________________
Street Address:__________________________________________________
City:_____________________STATE:______________ZIP:_____________

GROUP TRAVEL INFORMATION
Date of Trip:______________________Departure Time:_______________
Departing from (City/State):______________________________________
Destination (City/State):_________________________________________
Number of miles (one-way - Min 25 Miles):_________________________
Carrier:______________________________________________________
(MUST BE COMMERCIAL, CERTIFIED, AND INSURED)

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
MAIL COMPLETED FORM TO:

John and Rosilyn Earley
9422 Plowden Mill Road
Alcolu, S.C. 29001
(803)-473-5713