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
Organization / Business Name *

Address *

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

Phone: *

- Area Code Phone Number
Meeting Contact:
Name: *

First Name Last Name
Title: *
Phone Number: *

- Area Code Phone Number
E-mail: *
Meeting Details
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
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
until
: Hour Minutes
Set Up Time: *

: Hour Minutes
End Time: *

: Hour Minutes
Total No. Attendees Expected: *
Technology
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
Terms
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

Should be Empty:

Organization / Business

Meeting Contact:

Meeting Details

Technology

Terms