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Room/Facility Request Form

Request For Use of School of Dentistry Facilities

( * - Fields in red are required.)

Contact Information

Name of Responsible Person:
Organization or Department:
Permanent Address:
Telephone Number: Work:     Home:
  (999-999-9999)   (999-999-9999)
Email Address:

Event Information

Please indicate the period of the request:

(Include days, dates and times)

  Please indicate types of rooms requested and include number of rooms needed for each type of room:
Koury West Lobby: Yes:
Koury Small Seminar Room:

(seats 8, one seats 12, no projection)

Yes:       No. of Rooms:
Koury Large Seminar Room:

(seats 42, projector, laptop, whiteboard)

Yes:       No. of Rooms:
Koury Case Lecture Hall:

(105 stadium seats, video conferencing, projector, laptop, microphone, whiteboard, desks)

Yes:       No. of Rooms:
Kirkland Auditorium:

(220 stadium seats, projector, laptop, microphone, whiteboard)


(Main Street, Atrium or Exterior spaces. describe as necessary)

Please list below:

Special Needs:
Explain the purpose of the request:

  (How space(s) will be used i.e., classes, lessons, lectures, seminars, rehearsals, meetings, conferences, receptions, exhibits etc.)

If food is necessary, indicate type of meal(s):

(e.g, box lunches, buffet table, sit down event, beverages, snacks for breaks, etc. NOTE: No food is allowed in Kirkland Auditorium)

Approximately how many people will be involved?

(Include estimated audience, if any)

  Please provide the names of other persons sharing responsibility for the coordination or supervision of events:
1. Name:   Phone:
2. Name:   Phone:
Please provide the detailed schedule of activities:

(Include dates and times)

   I have reviewed the Policy on Use of School of Dentistry Facilities for Special Events