2011-17 Memorandum of Agreement for Polling Places - Pct # 15
The Owner (Occupant) agrees to provide a polling place for the following Municipal Election:
Primary Election: Tuesday, August 30, 2011
General Election: Tuesday, November 08, 2011
At the following location: Jenkins Auditorium - 691 Montrose St, Clermont
POLLING PLACE TELEPHONE NUMBER: 26,1 '399- '//
To the extent sovereign immunity has been waived, the County of Lake agrees to indemnify and hold harmless the
owner for any claims for bodily injury or property damage occurnng on the occupied premises arising from neghgent
acts of the County or any of its agents or employees. Lake County agrees to pay the amount of $ for
each election held at the above location.
CHECK SHOULD BE MADE PAYABLE TO:
MAILING ADDRESS:
Do you have Tables and Chairs available for the election board members to use on election day? Yes )(No
YOUR SPECIAL INSTRUCTIONS regarding use of building, delivery of equipment, election day, pickup of
equipment and any other instructions you may have.
Person(s) to contact for access to building preceding election for dehvery of voting equipment, 6:00 A.M. election day
for poll workers and after the election for pickup of voting equipment.
�� IF POSSIBLE PROVIDE TWO /` a ACT�O�LE � ��
Name /` UQ3 Name /�
Address ($ ( (.Q. 1 i l Q,'l l Oce S1 Address Coq (,)1 {' ) l6, - e
me,--yf- p, 3 », e mo- f- 34711
Phone Number 36 2 / 9 / Phone Number � z � 3 � V (/(
Cell Number q 6o cn -3 053 Cell Number
A KEY CAN BE OBTAINED FROM Name /-6 Phone Number ? `t [ -3 oo
Addres (q)
PLEASE FILL IN ALL INFORMATION u /
NEEDED AND RETURN ONE COPY O �, / / /
IN THE ENCLOSED ENVELOPE Signature of w er (Occu s i t)
Address
Asa - X 41 -1 - S3O
Phone Number
THANK YOU FOR YOUR COOPERATION
Election Office Phone Number Emogene W. Stegall
Lake County Supervisor of Elections
(352) 343 -9734 P. 0 Drawer 457, Tavares, Florida 32778