Suffolk County Legislature Form Center

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APPLICATION FOR BUILDING USE: LEGISLATIVE BUILDING/SPACE

  1. PART A: TO BE COMPLETED BY APPLICANT

  2. EQUIPMENT REQUESTED:

  3. (Please check all that apply)

  4. ___________________________

    OTHER EQUIPMENT REQUESTED - EXPLAIN BELOW

  5. SPACE REQUESTED

  6. (Please check all that apply)

  7. ____________________

  8. Is meeting open to the public?

  9. Place on Weekly Calendar?

    If you choose to place this event on our Weekly Calendar, it will go on our website and will be open to the public.

  10. CERTIFICATE OF INSURANCE REQUIRED FOR NON-COUNTY AGENCIES

    This application shall be accompanied by a Certificate of Insurance evidencing Commercial General Liability Insurance with a minimum limit of One Million Dollars ($1,000,000) per occurrence combined single limit for bodily injury and property damage with the County of Suffolk named as an additional insured. The Suffolk County Legislature may accept or reject insurance certificates as it may determine and may require other limits and/or coverage in specific instances.

  11. Certificate Received?

  12. HOLD HARMLESS AGREEMENT

    The applicant agrees to indemnify and hold harmless the County of Suffolk, its employees, officers, agents, or any other persons acting on its behalf, against loss or expense, including attorney’s fees, except in cases of the County’s negligence, for damage because of bodily injury including death at any time resulting therefrom, sustained by any person or persons; or on account of damage to property arising out of or in consequence of the use of property covered by this agreement, whether such injuries to persons or damage to property.

  13. Note:

    There are to be NO politically-related activities or signage on County property at any time.

  14. PART B: CERTIFICATION OF APPLICANT

  15. As a duly authorized representative of the group or organization named in this application, I have read and agree to abide by the above rules.

  16. THIS SPACE IS FOR OFFICE USE ONLY

  17. Please return completed, signed form to: Suffolk County Clerk of the Legislature, P.O. Box 6100, Hauppauge, NY 11788 via mail or scan & e-mail to WH_Rogers.Legislature@suffolkcountyny.gov or fax to (631) 853-4899.

  18. Leave This Blank:

  19. This field is not part of the form submission.