ࡱ> npm'` h3bjbj 04_   8L d ] zzzzzhlR#9#6]$^hCaZ]E"zz""Z]zz]VVV"XzzV"VVVz p  zdVn]0]Va aVaV""V"""""Z]Z]X"""]""""   NOTIFICATION OF AN EVENT/GROUP TRAVEL CALIFORNIA SQUARE DANCE COUNCIL INSURANCE PROGRAM NOTIFICATION OF AN EVENT This form is used for notification of an event where no Certificate of Insurance is required by the facility. If a certificate of insurance is not issued for a facility, there is no liability coverage for the facility being used. If the facility requires a Certificate of Insurance or to be named as Additional Insured, use the Request for a Certificate form. ASSOCIATION: Northern California Square Dancers Association INSURANCE CHAIRMAN: Peggy Rose and Ethlyn Babe Sandau CHAIRMAN'S ADDRESS: P.O. Box 1117 CITY: Brentwood STATE: CA ZIP: 94513-3117 TELEPHONE NUMBER: (925) 240-1117 TYPE OF FUNCTION - CHECK ONE  FORMCHECKBOX  EXHIBITION DANCE  FORMCHECKBOX  CLUB DANCE  FORMCHECKBOX  GROUP TRAVEL CLUB NAME:  FORMTEXT       CLUB ADDRESS:  FORMTEXT       CITY:  FORMTEXT       STATE:  FORMTEXT    ZIP:  FORMTEXT       DATE OF FUNCTION:  FORMTEXT       FACILITY BEING USED:  FORMTEXT       STREET ADDRESS:  FORMTEXT       CITY:  FORMTEXT       STATE:  FORMTEXT    ZIP:  FORMTEXT       GROUP TRAVEL INFORMATION DATE OF TRIP:  FORMTEXT   / FORMTEXT   / FORMTEXT    DEPARTURE TIME:  FORMTEXT       DEPARTING FROM (CI%'>GXYZrtZ w x  4 5 ⷧ⛎~qaUh<[CJOJQJ^Jh<[hL5OJQJ^JaJh<[5OJQJ^JaJhRh 0HCJH*OJQJ^Jh6\5CJOJQJ^Jh6\CJOJQJ^JhRh 0H0J5OJQJ^J hRh 0H0JCJOJQJ^JhRh 0HOJQJ^JhRhF"OJQJ^JhRh 0HCJOJQJ^JhRh 0H5OJQJ^J&'GYZst Y | }}}}  d$d0&d0N0P0gd% d d $ _da$ _d*$ $d %d &d 'd N O P Q a$ $ a$ )f35 X Y n { | ĴѥіѥѥіѥĄtdtdtdThRh 0H6CJOJQJ^Jhm1hm15OJQJ^JaJhm1h)<5OJQJ^JaJ"hm1hL5>*OJQJ^JaJhRhNCJOJQJ^JhRhCJOJQJ^Jhm1hL5OJQJ^JaJhm15OJQJ^JaJhRh 0HCJOJQJ^JhRhLCJOJQJ^Jh<[h<[5OJQJ^JaJ o  T ^ d((r))  gdpF  dgdpF$  dh$d0N0a$gd%   gd9    d d  dh$d0&d0N0P0gd%    $ % 3 4 5 O P ^ _ ` { | ﾘvaQ9a.jhc7hE5OJQJU^JaJhc7hL5OJQJ^JaJ(jhc7hL5OJQJU^JaJ+jhLhEOJQJU^JaJhLOJQJ^JaJjhLOJQJU^JaJ+j hLhEOJQJU^JaJhRh 0HCJOJQJ^J+jh \hEOJQJU^JaJh \OJQJ^JaJjh \OJQJU^JaJ  , . B D F P R b d x z | пРаРpаaRРhRhLCJOJQJ^JhRhNCJOJQJ^J.jhc7hE5OJQJU^JaJ.jhc7hE5OJQJU^JaJhc7hL5OJQJ^JaJhRh 0HCJOJQJ^J hRh 0H0JCJOJQJ^J(jhc7hL5OJQJU^JaJ3jhc7hL5OJQJU^JaJmHnHu   6 8 L N P Z \ ӹӪ|dӹU|=ӹ.jx hc7hE5OJQJU^JaJhRhLOJQJ^JaJ.j hc7hE5OJQJU^JaJhc7hL5OJQJ^JaJhRhLCJOJQJ^JhRhNCJOJQJ^JhRh 0HCJOJQJ^J3jhc7hL5OJQJU^JaJmHnHu(jhc7hL5OJQJU^JaJ.j hc7hE5OJQJU^JaJ\   "$.04<LNb̴ܚ܋sܚ[ܚLhRhNCJOJQJ^J.jhc7hE5OJQJU^JaJ.jdhc7hE5OJQJU^JaJhRh9OJQJ^JaJ3jhc7hL5OJQJU^JaJmHnHu.jBhc7hE5OJQJU^JaJhc7hL5OJQJ^JaJ(jhc7hL5OJQJU^JaJhRh 0HCJOJQJ^JbdfjlpxӹӪӋsӹcUcH3(jhc7hc75OJQJU^JaJhRh 0HOJQJ^JhRh 0H5OJQJ^JhRh 0H5CJOJQJ^J.jhc7hE5OJQJU^JaJhc7hL5OJQJ^JaJhRhNCJOJQJ^JhRh 0HCJOJQJ^J3jhc7hL5OJQJU^JaJmHnHu(jhc7hL5OJQJU^JaJ.jxhc7hE5OJQJU^JaJ 468<>@BVXZ^`d¨œ¨œl¨_RC_hRh 0HCJOJQJ^JhRh9OJQJ^JhRh 0HOJQJ^J.jhc7hNi5OJQJU^JaJ.j|hc7hNi5OJQJU^JaJhc7OJQJ^JaJ3jhc7hc75OJQJU^JaJmHnHu(jhc7hc75OJQJU^JaJ.j>hc7hNi5OJQJU^JaJhc7hc75OJQJ^JaJ((((.(0(2(<(>(seOs7s/jhBhc75OJQJU^JmHnHu*jhBhNi5OJQJU^JhBhc75OJQJ^J$jhBhc75OJQJU^JhRh 0HOJQJ^JUhRh 0HCJOJQJ^JhRh9OJQJ^J/jhc7hL5OJQJU^JmHnHu*jhhc7hE5OJQJU^Jhc7hL5OJQJ^J$jhc7hL5OJQJU^JTY/STATE):  FORMTEXT      ,  FORMTEXT    DESTINATION (CITY/STATE):  FORMTEXT      ,  FORMTEXT    NUMBER OF MILES (ONE WAY):  FORMTEXT      CARRIER:  FORMTEXT           August 2009 >(B(D(X(Z(\(`(b(d(((((((((տ㙊wiSw;w0hc75OJQJ^J/jhc7hL5OJQJU^JmHnHu*jhc7hE5OJQJU^Jhc7hL5OJQJ^J$jhc7hL5OJQJU^JhRh 0HCJOJQJ^JhRh9>*OJQJ^J/jhc7hc75OJQJU^JmHnHu*jHhc7hNi5OJQJU^Jhc7hc75OJQJ^J$jhc7hc75OJQJU^Jhc7OJQJ^J(((((((())) )4)6)8)@)B)r))𬝎{mW{?{2hRh 0HOJQJ^J/jhc7hL5OJQJU^JmHnHu*jhc7hE5OJQJU^Jhc7hL5OJQJ^J$jhc7hL5OJQJU^JhRhCJOJQJ^JhRh 0HCJOJQJ^JhRh9>*OJQJ^J)jhc75OJQJU^JmHnHu*jBhc7hNi5OJQJU^Jhc75OJQJ^Jjhc75OJQJU^J)))))))))))))))))))*2^3`3b3d3f3h3뚋wogeg]RNhF"hwPhF"CJaJh 5CJaJUh\CJaJhc7CJaJhF"CJaJhvjhvUhRh 0HCJOJQJ^JhRh 0HOJQJ^JaJ3jhc7hL5OJQJU^JaJmHnHu.j hc7hE5OJQJU^JaJhc7hL5OJQJ^JaJ(jhc7hL5OJQJU^JaJ))))))))))b3d3f3h3 $d0N0gdpF Rev 3 .:p6\/ =!"#$%  DCheck1fCheck this box, if you are performing an exhibition dance and no Certificate of Insurance is required.fCheck this box, if you are performing an exhibition dance and no Certificate of Insurance is required.DCheck2`Check this box, if you are dancing at this location and no Certificate of Insurance is required.`Check this box, if you are dancing at this location and no Certificate of Insurance is required.DCheck3XCheck this box, if you are traveling as a group to attend a dance by Commercial Carrier.XCheck this box, if you are traveling as a group to attend a dance by Commercial Carrier.DText8TEnter full Name of Club. BE CONSISTENT WITH THE NAME YOU USE ON ALL FORMS SENT IN !TEnter full Name of Club. BE CONSISTENT WITH THE NAME YOU USE ON ALL FORMS SENT IN ! DText9+Enter address of Club contact for function.+Enter address of Club contact for function.DText10$Enter city where Club contact lives.$Enter city where Club contact lives.D UPPERCASE"Two letter abbreviation for state."Two letter abbreviation for state.D Text12Zip code + four.Zip code + four.DText13Enter date of function in "mm/dd/yy" for Exhibition and Club dances. If more than one day, enter the word "to" between dates. LEAVE BLANK FOR GROUP TRAVEL ! Enter date of function in "mm/dd/yy" for Exhibition and Club dances. If more than one day, enter the word "to" between dates. LEAVE BLAN"DText14kEnter Facility name for Exhibition and Club Dances along with name of room. LEAVE BLANK FOR GROUP TRAVEL !kEnter Facility name for Exhibition and Club Dances along with name of room. LEAVE BLANK FOR GROUP TRAVEL !DText15EEnter address of Facility being used. LEAVE BLANK FOR GROUP TRAVEL !EEnter address of Facility being used. LEAVE BLANK FOR GROUP TRAVEL !DText16EEnter city where Facility is located. LEAVE BLANK FOR GROUP TRAVEL !EEnter city where Facility is located. LEAVE BLANK FOR GROUP TRAVEL !DText17 UPPERCASE"Two letter abbreviation for state."Two letter abbreviation for state.D Text18Zip code + four.Zip code + four.>DText19rEnter date in "mm/dd/yy" format. REQUIRES A MINIMUM OF 10 INSURED CLUB MEMBERS TO BE CLASSIFIED AS GROUP TRAVEL !rEnter date in "mm/dd/yy" format. REQUIRES A MINIMUM OF 10 INSURED CLUB MEMBERS TO BE CLASSIFIED AS GROUP TRAVEL !vDText28vDText29DText20PEnter the time the Group is departing from the first location, if more than one.PEnter the time the Group is departing from the first location, if more than one.*DText21-Enter location where Group is departing from.-Enter location where Group is departing from.DText30 UPPERCASErDText23?Enter the address of the dance to which the Group is traveling.?Enter the address of the dance to which the Group is traveling.DText31 UPPERCASEJDText25uDistance between Departure location and Destination Location. MINIMUM DISTANCE MUST BE 25 MILES OR GREATER ONE WAY !uDistance between Departure location and Destination Location. 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