Suffolk County Legislature Form Center

2. PART A: TO BE COMPLETED BY APPLICANT
4. Date Requested*
   Date Requested Start Date

   Date Requested Start Time

   —

   Date Requested End Date

   Date Requested End Time

    (Date Requested From - Date Requested To)

6. Actual Start Time of Meeting*
   Actual Start Time of Meeting

   (The time the meeting will begin)

8. If recurring event, please indicate future dates:
10. Name of Group/Organization*
12. Requested Location*

     (Please check all that apply)

    1. Lobby
    2. Clerk's Conference Room
    3. Downstairs Conference Room
    4. Rose Y. Caracappa Auditorium (H)

    1. Maxine S. Postal Auditorium (R)
    2. Front of Building
    3. Other:
14. Other Space Requested (please explain):
16. Telephone # of Group*
18. Address (Number and Street)*
19. Town or Village & Zip*
20. County*
22. Contact Person*
23. Contact E-mail Address*
25. Contact Person’s Phone #’s*
27. Is meeting open to the public?

    1. Yes
    2. No
28. 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.

    1. Yes
    2. No
30. PART B: EQUIPMENT REQUESTED:
32. (Please check all that apply)

    1. Easels
    2. Flags
    3. Podium

    1. Speaker Phone
    2. Digital Audio Recorder
    3. Sound System/Microphones

    1. Photographer
    2. Videographer
    3. Other
34. Other Equipment Requested (please explain):
36. Electronic Presentation Form
    Schedule an Electronic Presentation

    A link for a separate fillable form required for electronic presentations will be on the confirmation page upon submission of this form. It can also be found clicking on the provided link above.

38. Nature of Event (describe in detail): *
39. # of Attendees?
41. 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.
42. Certificate Received?

    1. Yes
    2. No
    3. Waiver Submitted
46. 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.
47. Note:
    There are to be NO politically-related activities or signage on County property at any time.
51. PART C: CERTIFICATION OF APPLICANT
53. 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.
55. Print Name of Applicant:*
59. THIS SPACE IS FOR OFFICE USE ONLY
65. 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) 853-4071.
Leave This Blank:


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit Submit and Print

* indicates a required field