Requestor Name: Phone:

Email: Department:

Is this a fundraising event? Yes No (If yes, please complete the fundraising request form and send per the instructions on the form.)

Date Requesting:

Time: From: AM PM To: AM PM

Event Title/Description:

Will food or beverage be served? Yes No

Will alcohol be served? Yes No (please be sure that you've read and understand the Serving Alcoholic Beverages Policy)

Location Preference: (Please select 1st, 2nd and 3rd choices)

1st choice: Select One Durham Outpatient Center West Lobby Atrium Durham Outpatient Center Central Atrium Durham Research Center I Atrium Durham Research Center II Commons Area Durham Plaza (by Swanson Hall) North Plaza (Eppley Courtyard) South Plaza (Bennett Courtyard) East Plaza (College of Pharmacy Courtyard)

2nd Choice: Select One Durham Outpatient Center West Lobby Atrium Durham Outpatient Center Central Atrium Durham Research Center I Atrium Durham Research Center II Commons Area Durham Plaza (by Swanson Hall) North Plaza (Eppley Courtyard) South Plaza (Bennett Courtyard) East Plaza (College of Pharmacy Courtyard)

3rd Choice: Select One Durham Outpatient Center West Lobby Atrium Durham Outpatient Center Central Atrium Durham Research Center I Atrium Durham Research Center II Commons Area Durham Plaza (by Swanson Hall) North Plaza (Eppley Courtyard) South Plaza (Bennett Courtyard) East Plaza (College of Pharmacy Courtyard)

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