Name of organization: ___________________________________________________

Name of contact person:__________________________________________________

Number where contact person can be reached:_________________________________

Date of display: _________________________________________________________

Purpose of display:_______________________________________________________

Brief description of display:________________________________________________

Time:

I would like to set up my display on : _________________________________________

                                                                              (date)

I will take my display down on: ______________________________________________

                                                                               (date)

Tables are available from the library for your convenience.  Inquire about sizes.  Will you need a table?__________

 The library is not responsible for any loss or damage to your display.

I agree with the attached policy and understand the library does not insure displays.  I understand all reasonable precautions will be taken to protect my materials, but the library is not responsible for reimbursement or replacement of lost, stolen or damaged articles.

Signature_______________________________________________________________

Date___________________________________________________________________

This form must be turned in to the Library Director for approval.

Scott County Public Library

104 S. Bradford Lane

Georgetown, Kentucky 40324