Form 12 – Application for Hire / Casual Use

Form 12 – Application for Hire / Casual Use
Club / Organisation Name:
Address:
Contact Person:
Contact Phone No:
Ground / Facility Required:
(Separate applications are
required for each ground)
Summer
Winter
Usage:
Date(s)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Times Required
(1 October to 31 March) q
(1 April to 30 September) q
Date/s
(ie. 1/1/08, 8/1/08)
Function/Event
From……....………am/pm
To…………...…......am/pm
From……....………am/pm
To…………...…......am/pm
From……....………am/pm
To…………...…......am/pm
From……....………am/pm
To…………...…......am/pm
From……....………am/pm
To…………...…......am/pm
From……....………am/pm
To…………...…......am/pm
From……....………am/pm
To…………...…......am/pm
Alcohol - Will alcohol be sold to the public:
YES / NO (Attach Permit)
Public Liability Insurance
A Certificate of Currency or copy of current Public Liability Insurance Policy MUST be attached
to this Application.
Certificate/Policy Number:
Expiry Date:
Amount of Cover (Min $10m):
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TERMS AND CONDITIONS
In this Agreement:(1) T
he Committee is charged by the Golden Plains Shire with the management and control of the
……………………………………….. (Name of facility) and entitled to enter into this Agreement for the hiring of the
premises to the Hirer.
(2) The person or persons by whom the application form is signed shall be considered the Hirer. Their liability under this
Agreement shall be joint and several.
(3) All charges in relation to hire must be paid in full by the due date, unless the Committee has approved suitable
arrangements.
(4) The Council reserves the right to approve the use of the ground by other persons at any time not specified in this
application at any time when the ground is not required for use by hirer.
The Council may require the hirer to make available any building or facility on the ground to another hirer where such
building or facility is not the property of the hirer.
The Council reserves the right to cancel the hirers’ use of a recreation ground on a date shown in this application in the
event of the ground being required for an extraordinary function or extraordinary use.
The Council reserves the right to close a ground for use, or redirect users to an alternate ground where in the opinion of
Council’s Works Manager, conditions render the ground unsuitable for use.
(5) The Hirer shall not sub-let the premises or any part thereof nor sell nor offer for sale, assign, mortgage, pledge, underlet,
deal with or remove from the premises any equipment or any part thereof or any interest therein, or any interest in this
agreement and will not create or allow to be created any lien upon the equipment and will protect the equipment against
distress, execution or seizure.
(6) The Committee shall not be responsible for any loss of or damage to any property arising out the hiring from any cause
whatsoever or for any loss due to the breakdown of machinery, failure of supply of electricity, leakage of water, fire,
governmental restriction or any other matter beyond the reasonable control of the Committee which may cause the
premises to be temporarily closed or the hiring to be cancelled.
(7) The right of entry to the premises is reserved to every other agent or agents of the Council, Committee and any Police
Officer at any time during the Term.
(8) The Hirer agrees to indemnify and to keep indemnified, the Council and the Committee, its servants and agents,
and each of them from and against all actions, costs, claims, charges, expenses, penalties, demands and damages
whatsoever which may be brought or made or claimed against them, or any of them, arising from the Hirers
performance or purported performance of its obligations under this Agreement and be directly related to the negligent
acts, errors or omission of the Hirer.
(9) The hirer shall at all times during the allocated period of hire insure and keep insured with an insurance company
approved by the Council against public risk for an amount of not less than $10 million.
(10) The hirer is responsible for obtaining the appropriate Insurance to cover all equipment owned by the hirers. Hirers
are advised to take precautions to ensure that equipment is stored safely. Council/Committee will not take any
responsibility for equipment owned by the hirer.
(11) Hires shall ensure that equipment is stored away, floors are swept/vacuumed and the toilets are inspected prior to
leaving the premises after each use. Lights and hot water turned off and all doors locked. Refrigerators left as they
were found.
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(12) If the Hirer intends to allow the consumption or supply of any alcoholic beverage whatsoever the Hirer shall obtain an
appropriate license from the Liquor Control Commission and shall, not less than one week before the commencement
of the term, show a copy of the license to the Committee. The Committee reserves the right to terminate this
Agreement for Hire forthwith in the event that an appropriate license is not produced within the time stipulated.
• The use of hay bales or similar inflammable materials in the facility is prohibited.
• No glass is to be brought into the facility or left in rubbish containers.
• All functions must finish at 1.00 a.m. unless by prior negotiation.
• No smoking is permitted upon the premises.
• No bolts, nails, screws, pins etc shall be driven into any part of the premises.
• No vehicles, horses or golf practice/playing are permitted at/on the facility without written permission.
(13) T
he Hirer shall immediately prior to the conclusion of the term leave the premises clean and secured at the conclusion
of the Hirer’s use thereof on the last day of the term to the satisfaction of the Committee, unless the Committee shall
otherwise have agreed in writing to the Hirer.
(14) T
he approval to the hirer is subject to the approval from the Committee of Management. The APPLICANT is
responsible for contacting the Committee who must be notified and agree to all conditions of use. Please indicate
the Committee and person contacted. If you are unsure of the Committee of Management, or contact person please
phone the Golden Plains Shire.
Facility:
Contacted:
Position at Committee:
APPROVED:
CHECKED:
Via Phone
q
Via Email
q
UNDERTAKING
I …………………………………… of …………………………………………… hereby make application for use of the above
Council ground for the dates and times specified and acknowledge having received and read the Terms and Conditions of
hire and undertake to be bound by and comply with the Terms and Conditions in every respect and I further undertake to
be responsible for ensuring that all individuals or groups using the ground in association with this application comply with
the terms and conditions.
SIGNATURE OF APPLICANT:
DATE:
The Golden Plains Shire considers that the responsible handling of personal information is a key aspect of democratic
governance, and is strongly committed to protecting an individual’s right to privacy. Council will comply with the Information
Privacy Principles as set out in the Information Privacy Act, 2000. Council has in place a standard operating procedure that
sets out the requirements for the management and handling of personal information.
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COMMITTEE / OFFICE USE ONLY
APPLICATION: ‘COMMITTEE’ APPROVED/REFUSED (Reason refused)
APPLICATION: ‘REGULAR USER GROUP’ APPROVED/REFUSED (Reason refused)
SPECIAL CONDITIONS? YES / NO Specify
TEMPORARY STRUCTURE PERMIT REQUIRED? YES / NO
SIGNED BY
DATE
(Committee of Management)
Hire / Casual Fee: Charge Raised Yes / No
AMOUNT $
Signed
DATE
The Golden Plains Shire considers that the responsible handling of personal information is a key aspect of democratic
governance, and is strongly committed to protecting an individual’s right to privacy. Council will comply with the Information
Privacy Principles as set out in the Information Privacy Act, 2000. Council has in place a standard operating procedure that
sets out the requirements for the management and handling of personal information.
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