Community Foundation of Greater Dubuque Request for Public Use

Request for Public Use
Type of Organization*

501(C)(3) Nonprofit Organization/ AgencyPublic Agency or Unit of Government (Town or County, School, etc.)Faith-Based InstitutionBusiness
Organization / Business
Organization / Business Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:*

Area CodePhone Number
Meeting Contact:
Name:*

First NameLast Name
Title:*
Phone Number:*

Area CodePhone 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:*

MonthDayYear
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:*

:HourMinutesAM/PM Option
until
until :HourMinutesAM/PM Option
Set Up Time:*

:HourMinutesAM/PM Option
End Time:*

:HourMinutesAM/PM Option
Total No. Attendees Expected:*
Technology
AV Needs:

Podium & MicrophoneWireless Lapel Microphone #1Wireless Lapel Microphone #2TV DisplayMotorized Screen Display
Phone Conferencing*

YesNo
How many remote attendees
Video Conferencing*

YesNo
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.*

YesOther
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 NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Should be Empty:

Organization / Business

Meeting Contact:

Meeting Details

Technology

Terms