2011-18 Memorandum of Agreement for Polling Places - Pct # 15
The Owner (Occupant) agrees to provide a polling place for the following three elections:
Presidential Preference Primary: Tuesday, January 31, 2012
Primary Election: Tuesday, August 28, 2012
General Election: Tuesday, November 6, 2012
At the following location: Jenkins Auditorium - 691 Montrose St, Clermont
POLLING PLACE TELEPHONE NUMBER:
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 occurring on the occupied premises arising from negligent
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 delivery 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 CO TACT P OPLE
Name L l)t 1-1-co i Name V
Address (C(( (i) , 1/14 niTfrasp Sf Address 6qr LO , (?y2 ce_
F I c , P 31-7 J
Phone Number 3gZ. t T - `t (Cf 1 Phone Number 35 2- - 4 I C 1
Cell Number ( 4 -0 " - ) ' ( (.0 0.1 Cell Number
A KEY CAN BE OBTAINED FROM Name 3
C � (� P Phone Number �� � � " T � '3 �S
Addres n CO • W , f' / ` tv +Oa -Z. -�
PLEASE FILL IN ALL INFORMATION
NEEDED AND RETURN ONE COPY C41A-taC_..)
IN THE ENCLOSED ENVELOPE Signature of wner (Occupan
Address
3Sa -;-(-1 I- 7 330
Phone Number
THANK YOU FOR YOUR COOPERATION
Election Office Phone Number Emogene W. Stegall
Lake County Supervisor of Elections
(352) 343 -9734 P. O. Drawer 457, Tavares, Florida 32778