Petitioner Request

Petitioner Request

This form is used for any political related activity on a Coconino Community College campus including voter registration initiatives.
Is your organization:*

For-profitNon-profit
Coconino Community College welcomes petitioners to our campuses and asks that you complete the form below to schedule your visit. Petitioners are welcome to campus during regularly scheduled campus hours.

Petitioners are subject to all College policies and procedures including Procedure 120-02 Petition Signature Solicitation. Petitioners are asked to avoid being an obstruction to student activities and to avoid disruptions to the College environment. This procedure also prohibits the distribution of any item except for materials related to the candidate, voter registration, or ballot initiative.

A table and chairs are available upon request and will be charged according
to the Facility Use Fee Schedule (For-profit organizations $50, non-profit organizations no charge).
Contact Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Organization Name*
Date and Time Information
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Other Date Information
If your request includes more than one date, please indicated the start and end date for your request and indicate the dates you will actually be using the table in the box above.
Start Time*

Hour Minutes

AM/PM Option
End Time*

Hour Minutes

AM/PM Option
Preferred Campus*

Lone Tree - 2800 S. Lone Tree Rd., Flagstaff, AZ 86005Fourth Street - 3000 N. Fourth St., Flagstaff, AZ 86004
For petitioner information at the Page Center, contact Jessica Dodson at 928-645-6683 or jessica.dodson@coconino.edu.
Other Campus Information
If you will be hosting tables at more than one campus, please indicate the dates for each campus in the box above.
Would you like a table and chairs ($50 for for-profit organizations and $25 for non-profit organizations)?

YesNo
Insurance Information
All non-college parties must submit a certificate of insurance naming the College and including the address of the facility being used. Commercial general liability insurance should have minimum limits of $1,000,000 per occurrence. For assistance with a certificate of insurance, please contact your insurance agent.
Please upload a certificate of insurance

Cancelof
Applicant terms, conditions and signature
Applicant agrees to hold CCC harmless and will indemnify CCC for damages sustained as a result of injury or property damage for which CCC may be held responsible, as part of this request for use of CCC property.

Applicant understands that food and beverages may not be offered as part of this request and only items related to the candidate/ballot initiative may be passed out.

The College reserves the right to cancel any reservation if deemed to be in its best interest to do so. The College will not be responsible for financial loss to a potential user if such cancellation is communicated five (5) calendar days before the scheduled facility use date. The College will not be responsible for financial loss to a potential user if the facility is made unavailable because of acts of God or any other circumstances beyond its control.
By signing this document, I agree to abide by the rules stated above as well as Coconino Community College Policies and Procedures. I understand this agreement is not transferable to any other individual or group.*

Clear
Signature Date*

MonthDayYear
Date
Should be Empty:

Petitioner Request

Contact Information

Date and Time Information

Insurance Information

Applicant terms, conditions and signature