Community Foundation of Greater Dubuque Request for Public Use

Request for Public Use

Type of Organization *

501(C)(3) Nonprofit Organization/ Agency Public Agency or Unit of Government (Town or County, School, etc.) Faith-Based Institution Business

Organization / Business Name *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone: *

Area Code Phone Number

Name: *

First Name Last Name

Title: *

Phone Number: *

Area Code Phone Number

E-mail: *

Name of Meeting: *

Please make sure this is the same name of the meeting that your guests will be asking for.

Purpose of Meeting: *

Date of Meeting: *

Month Day Year Date Picker Icon

The McCarthy Center hours of operation are 7 a.m. to 8:00 p.m. Monday - Sunday.

*Please note: If your meeting takes place outside of Community Foundation business hours (Monday to Friday, 8 a.m. - 4:30 p.m.), staff will not be available for assistance.

Meeting Time: *

: Hour Minutes AM/PM Option

until

until : Hour Minutes AM/PM Option

Set Up Time: *

: Hour Minutes AM/PM Option

End Time: *

: Hour Minutes AM/PM Option

Total No. Attendees Expected: *

AV Needs:

Podium & Microphone Wireless Lapel Microphone #1 Wireless Lapel Microphone #2 TV Display Motorized Screen Display

Phone Conferencing*

Yes No

How many remote attendees

Video Conferencing*

Yes No

How many remote attendees

I certify that I have read the Guidelines for Public Use and agree to abide by them. *

Yes

Click here to read Guidelines for Public Use.

I understand I will be billed if the post-event checklist is not fully completed. *

Yes

Name of Organization / Business requesting public use *

hereafter referred to as Organization, agrees to indemnify, defend, and hold harmless the Roshek Building and its officers, directors, agents, and employees, as well as those of its tenant, CFGD, from and against any and all demands, claims, and damages to persons or property, losses and liabilities, including reasonable attorney's fees, arising out of or caused by Organization's or Organization’s meeting attendees' negligence or willful misconduct.

SIGNATURE STATEMENT: As official representative on behalf of the Organzation / Business named in this request, I accept the above terms.

Name *

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Organization / Business

Meeting Contact:

Meeting Details

Technology

Terms