Manitowoc County Historical Society

1701 Michigan Ave.

Manitowoc, WI  54220 

Organization Name_______________________________________________________________

Contact Person __________________________________________________________________

Address________________________________________  Phone # ________________________

Fax # __________________________  Email __________________________________________

Liability Insurance Agent: _________________________________________________________

Address ________________________________________  Policy # ________________________

Facilities Requested          0 Mirro Auditorium        0 Learning Center

Primary Purpose of Activity

0 General Mtg                  0  Dinner                             0  Civic Activity

0 Reception                      0  Awards Ceremony          0 Rehearsal

0 Performance                 0 Entertainment                   0 Other_______________________

0 Recital                           0  Luncheon

Describe Activity_________________________________________________________________

Number of people in attendance__________   Will food/ refreshments be served? __________   Name of caterer _______________________    Phone # _________________________________

Date(s) Requested                     Building Open Time                           Building Close Time

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Do you need room set up?  ___________  Describe needs ______________________________

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MCHS Volunteer or Staff person on duty _____________________________________________

Price quoted ______________________

Notes: