Meeting Type: _________________________________________________________________
Brief Description: ______________________________________________________________
Meeting Room # 1 (max 30 ppl) Meeting Room # 2 (max 100 ppl)
Green House #1 (max 100 ppl) Other (specify) _________________________
Date(s) of Event: ________________________
No. of Guests: ________________ Start Time: ____________ End Time: _____________
(Note: The allotted hours must include time for set-up and clean-up)
Organization: _________________________________________________________________
(if 501(C), attach a copy of official designation)
Applicant's Name: _____________________________________________________________
Address: _____________________________________________________________________
City: __________________ State: _________ Zip: _________ Phone: ____________________
E-Mail: __________________________________________
Applicant’s Signature ___________________________________ Date: ___________________
In the event of a cancellation, please contact ____________________ ____________________
Please Print Name Phone Number
Release and Hold Harmless
The undersigned is being granted a permit for the use of Town property and/or Town facilities and herby agrees to assume responsibility and all risk of
loss and shall be responsible for the supervision and welfare of all persons arriving on and / or using Town property and/or facilities in connection with
permit issued. The undersigned further hereby releases the Town of Brookhaven, its officers, employees, servants, agents and enumerated volunteers
from any liability for any injuries sustained or damages incurred, and to reimburse the Town for any damages arising out of directly or indirectly relating
to the undersigned's use of the Town property and / or facilities. The undersigned hereby further agrees that (he/she) will indemnify and hold harmless
the Town of Brookhaven, its officers, employees, servants, agents and enumerated volunteers harmless from any liability or claims that may result from
the use of the Town property and/or facilities arising out of said permit.
Applicant's Signature ___________________________________ Date: _______________
Fee calculation:
Meeting fee (first 2 ½ hrs.) $ x # mtgs
Meeting fee (additional hrs.) $ x # mtgs
Social Activity fee (first 5 hrs.)
Social Activity fee (additional hrs.) $ x # hrs
Photos (# hours x $50) # hrs
Damage Deposit (If paying the above fee by check or
credit card, this portion of the payment MUST be made
Deposit $100
Official Use Only Permit#: ______________
Received by: __________________________ Approved By: ______________________________
Check #: __________________ Amount: $_________________ CC authorization # _____________
$
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