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IfVERSITY CLUB OF TAMPA RESERVAT^ REQUEST

IMPORTANT: Completion and execution of this form is required by the Federal
Income Tax Laws. The form, and your answers reflected thereon, will be sub-
ject to review by the Internal Revenue Service and verification of your
answers may be required by an Internal Revenue Agent.

I. lub Account tlo. 3 apply for
Print Name). /) '-
reservation of the /AV w, A Room of the Club for a Function to be held
between the hours of and //9j, On the day ofAY ~ ,I .19 .
With respect to said function, I hereby represent as follows: (Check each
applicable box and answer each applicable question.)
1. =7 The function will be my own private party attended only by me
and my bona fide guests and I will not be reimbursed for any part
of the expenses thereof.
2. f I will be reimbursed for all or a part of the expenses of the
fun tion
(If you have checked the No. 2 box, supply the following information.)
(a) Name and address of the person or company who or which will
reimburse me

(b) My relationship to such person or company is _

(c) The purpose of the function is

(d) Approximate number of people at function will be
(e) Approximate number of Club members at function will be

I understand that if the function described above is held at the University
Club and if I have checked the No. 2 box above, I will be supplied an
additional form which I must fill out and return to the Club within one
week after the function is held.

DATED _____


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