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2. Name of Requesting Group/Organization:*
4. Type of Group/Organization:*

   1. Non-Profit
   2. Educational Group
   3. Civic Group
   4. Homeowner Association
   5. Other
5. If Other, please specify:
7. Description of Meeting*

   Please briefly describe the reason for this meeting.

9. Requested Date*
   Requested Date
10. Requested Start and End Time*
    Requested Start and End Time Start Time

    —

    Requested Start and End Time End Time

    The outside entry door to the building and meeting room will open 15 minutes before start time to allow for set up time and lock 15 minutes after the start of the meeting.

12. Requested Room*

    1. Meeting Room A - capacity up to 50
    2. Meeting Room B - capacity up to 100
13. Estimated Number of Attendees*
    -- Select One --Less than 1515-2525-3031-4041-5051-6061-7075 or above
15. Additional Audio/Visual Equipment Use Request

    The projector is available for your use, you will need a device that supports HDMI or DisplayPort to connect to the projector. Please select yes if you will require any other type of equipment use above and beyond this.

    1. Yes
    2. No
17. Primary Contact*
19. Email Address*
20. Phone Number*
22. Address
24. City
25. State
26. Zip Code
28. Terms, Conditions & Requirements

    In case of loss or damage to Village furniture, equipment, and/or building, groups will be responsible for the cost of replacement and/or repair. The Village is not responsible for the loss of or damage to any equipment or materials owned or rented by an individual, group, or organization using its premises. Any group or organization using the meeting rooms hereby indemnifies, protects, and holds harmless the Village of Palatine, its Mayor & Village Council, and Village Staff, for any and all accidents, including personal injury, property damage, and theft, which may be sustained on the premises.

30. I have read and agree to all terms, conditions and requirements of the Village’s Public Meeting Room Policy and Application.*

    1. Yes
32. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree
34. Electronic Signature*
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field