THE JUDICIARYSTATE OF HAWAI217IAPPLICATION FOR USE OF JUDICIARY FACILITIESDate:Applicant:Organization:Participants:Address:Telephone:The use of the following Facility:is requested forfrom:for the purpose of(THREE (3) or MORE SHERIFFS REQUIRED FOR 25 OR MORE)(BUILDING AND ROOM NUMBER)(DATE) Number of(TIME)I, the undersigned, on behalf of the organization I represent, will be responsible for the proper care of thebuildings, equipment, and facilities; the payment of the charges as shown below, assessed in accordancewith the Judiciary policies and procedures; and complying with the conditions of use of this Judiciaryfacility. I further agree that all laws and Judiciary policies, including those that relate to fire regulations,alcoholic beverages, etc., will be complied with. I understand that arrangements for security coverage andpayment for services must be made by me and that the name of the individual hired to provide security willbe submitted at least two days prior to the scheduled event.Applicant220s Signature:Date: FOR OFFICIAL USE ONLY: USER CHARGE(S): $ FOR: ESTIMA TE: ACTUAL:(Made payable to: STATE DIRECTOR OF FINANCE)Received Check#:Custodial Services:$$Utilities:$$INSURANCE REQUIRED:YES 002NO 002Others:$$SECURITY SERVICES REQUIREDYES 002NO 002*SECURITY SERVICES:$$ RECOMMENDED ACTION:ACTION:002 APPROVED002 APPROVED002 APPROVED with the following revision(s)002 DISAPPROVED002 DISAPPROVED DIVISION HEADDATE ADMINISTRATIVE DIRECTOR TO THE COURTSDATE* To be determined and charged by Sheriff220s DivisionReprographics (07/10)APPLICATION FOR USE OF JUDICIARY FACILITIES 1D-P1303FORM: 91-86-93[Rev: 11/2009](TWO sheriffs start at MINIMUM TWO HOURS / cost: $30.00 per hourper sheriff = $60.00 each) American LegalNet, Inc. www.FormsWorkFlow.com The undersigned individual(s), group and/or organization, his or their heirs, personal representative andassigns, or its officers, directors, members, agents, employees, successors and assigns, for and in considerationof the Judiciary, State of Hawai217i permitting and allowing the use of the designated facilities jointly andseverally agree(s) to indemnify and save harmless the Judiciary, State of Hawai217i against any and all loss,liability, demands, claims, suits, actions or proceedings of every name, character and description whichmay be suffered or incurred by or brought against the Judiciary, State of Hawai217i for or on account of anyinjuries or damages to any person or property received or sustained by any person, directly or indirectly, byor in consequence of the use of the facilities by the undersigned individuals(s), groups and/or organization.Signature:Date:Name of Organization (if applicable)FORM: 91-86-94[Rev: 11/2009]STATEMENT INDEMNIFYING JUDICIARY AGAINST LIABILITY CLAIMTHE JUDICIARYSTATE OF HAWAI217ISubscribed and sworn to before me thisday of, 20,personally appeared, to me known to be the person describedin the foregoing instrument and who acknowledged that he/she executed the same as this/her free act and deed.This one page, 215Statement Indemnifying Judiciary Against Liability Claim,216 datedat the time of notarization, was executed in the Circuit of the State of Hawai217i.Notary Public SignaturePrint Name and Commission NumberMy commission expires: ORDivision HeadDateReprographics (/)STATEMENT INDEMNIFYING JUDICIARY AGAINST LIABILITY CLAIM AD-E-678 American LegalNet, Inc. www.FormsWorkFlow.com CONDITION OF USE Cancellation. The Judiciary reserves the right to cancel a previously approved application due to unforeseenJudiciary business. Any usage charge deposited will be returned to the applicant. The applicant may alsocancel a reservation. However, any usage charge deposited will be returned only if the reservation iscanceled prior to the date of use. Liability. The user shall exercise due care for the public safety, and shall indemnify and hold harmless theJudiciary, its officers, agents and employees from and against all claims and demands for damages includingclaims for property damage, bodily injuries or death arising from, growing out of or caused by any act oromission on the part of the user, its officers, agents, members, or employees in connection with the privilegeof using Judiciary property. The user shall complete and submit Form 91-86-94, 215Statement IndemnifyingJudiciary Against Liability Claim216 together with this application. The Judiciary may require the user toobtain general liability insurance. Fixtur es, burning and noise. No sign, poster, fixture, or object of any kind shall be attached to any part ofJudiciary property, unless prior approval has been received from the Judiciary. No burning of any kindshall be permitted, and no alcohol shall be served or consumed on the premises. Noise shall be kept to aminimum, and use shall cease if the noise is determined by the Judiciary to be excessive. Equipment and personnel. The user shall provide all necessary equipment and personnel. The Judiciaryis not obligated in any way to provide either equipment or services. Moving of pr oper ty pr ohibited. No Judiciary fixture, equipment, or furnishing of any kind shall be movedor removed for any reason, except that tables and chairs may be arranged to suit the occasion but it is theresponsibility of the user to replace these items to their original positions. Pr ecautions. The user agrees to take necessary action and other precautions to prevent damage to Judiciaryproperty and to ensure the safety of persons using Judiciary property. Security services. Security personnel are required unless specifically waived by the Judiciary. Deputysheriffs of the Department of Public Safety shall be used unless the Judiciary determines that police officersare required. The user shall be responsible to arrange for security service and shall provide the Judiciarywith the names of the security officers at least two (2) business days prior to use of the facility. Additionally,the user shall be responsible to make payment for security services in accordance with the policies of theOffice of the Sheriff or Police Department, as applicable. The Judiciary shall not be responsible for anyaspect of the payment process or payment for security services. Damages and clean-up. The user shall assume responsibility for any physical damage caused by orconnected with the use of Judiciary property. All areas shall be left clean and all litter created by the usershall be collected and placed in trash containers. In the event of damage or uncleanliness, the Judiciarywill bill the user for the cost of correction or deficiencies. Form of payment. Payments shall be by cash, money order, certified check, or cashiers220s check. Paymentsto the Judiciary shall be made payable to the State Director of Finance and payments for security servicesshall be made in accordance with the procedures of the security services provider.Reprographics (07/10)1D-P-1303 American LegalNet, Inc. www.FormsWorkFlow.com