Durga Temple of VA

APPLICATION FOR THE VISIT OF DURGA TEMPLE

Action Requested :	Volinteer Work	Visit Start Date :
	Survey	Visit Start Time :
	Religious Study	Visit End Date :
	Others	Visit End Time :
Action Requested Full Detail & Reason of the visit :
Visitor’s Information (name must match your government issued ID):
*Visitor’s Name Last		First	Middle
*Number and Street or Route and Box Number (no P.O. Box here)	City	State	Zip Code
Email address (optional):
Drivers License / State ID #		State:
Phone (Home):		Mobile #:	Other #:
All school and student visitors must complete followings Section:
School Name:	School Phone:	School Email:
Project Teacher In-Charge Name:		Teacher Phone:
All Corporate initiated event must complete following section:
Company Name:
Company Address:
Manager/ Supervisor’s Name:		Phone #:	Email:
If this person is a minor,list the name, address, and phone number of the child’s custodial parent or legal guardian:

I also GIVE / NOT GIVE permission to receive temple’s communication in future.
I STATE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
10/3/2023 Date