SPAAMFAA
P. O. Box 2205
Syracuse. NY 13221-2005

Name of requesting Region or Chapter: _____________________________________________________________

Chapter contact person for this event:________________________________________________

Phone number: (___ )_______________ Date of Event:_________________________________

Approximate number of members that will attend: _______________ __________________ _________________

Type of event: _________________ ______________________________ ______________________________________

Will bleachers be used ? ______ ________ ___________ _________________ ________________________________

Will you be signing a lease of premise contract?______________________________________
(A copy of the lease or contract must accompany this request.)

Location of the event:____________________________________________________________

Owner of the premises where the event will be held:_____________________________________

Certificate requested by: _________________________________________________________

Certificate mailed to:________________________________________________________________________________

Special Instructions: _____________________________________________ _______________

_____________________________________________________________________________________________________

____________________________________________________________________________

Date form completed:_______________________

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Mail completed form 30 days in advance of event to:

Potter Emergency Insurance Service

P.O. Box 1967

Cicero, NY 13039-19ô7

Copyright © 1999, 2000 ODHFS, Inc.
Updated: February 13, 2000