Village Hall Upstairs Use Permit Applicant's Name * Required First Last Address * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone * RequiredEmail * Required Name of Organization And/Or Event * Required Head of Organization * Required Head of Organization Phone * RequiredPerson in Charge of Event Person in Charge of Event PhoneAlternate Person in Charge of Event Alternate Person in Charge of Event PhoneRequested Location * Required Event Date(s) * Required Time and Duration of Event * Required Type of Event * Required Purpose for this use * RequiredAgreement * Required I agree to the belowI agree to be responsible for the safe and orderly conduct of the group above and the associates thereof in attendance. I further agree that I, myself, or the alternate adult in charge shall be present and actively supervise the group and its associates from the beginning of the activity until all such persons have left the building. If neither undersigned person can be present to supervise, it is my responsibility to cancel the above activity and notify the Village Clerk before the activity was to begin. The applicant/organization is responsible for the cleanup of the room and other areas used for this event. The applicant agrees to pay all costs for said clean-up and will reimburse the Village of Greenwich for any and all additional custodial costs as well as other expenses incurred as a result of this activity. The applicant/head of organization has read and understands the Conditions for Use of Village Facilities on reverse side of this form. If the Village of Greenwich requires you to obtain insurance for this event, who will the insurance carrier be?Name of Company Agent's Name Insurance Carrier Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Carrier PhoneApplicant's Signature * RequiredDate of Signature - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Alternate Person in Charge of Event Signature * RequiredDate of Signature of Alternate Person in Charge of Event - must be mm/dd/yyyy format * Required MM slash DD slash YYYY INDEMNITY AND HOLD HARMLESS AGREEMENT To the fullest extent permitted by law, the Permit Holder shall indemnify and hold harmless the Village of Greenwich, its elected officials, officers, agents and employees from and against any and all claims, damages, losses, costs and expenses, including but not limited to reasonable attorneys fees, arising out of the use of the Premises and/or actions of the Permit Holder, its guests, employees, agents, contractors, suppliers, vendors, or anyone directly or indirectly employed by Permit Holder or anyone for whose acts Permit Holder may be liable. Applicant's Signature * RequiredDate of Signature - must be mm/dd/yyyy format * Required MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
