2. Name/Group*
4. Address
6. City
7. State
8. ZIP
10. Contact Person*
11. Phone*
    Enter as 999-999-9999
12. Fax
14. Email
16. Requested Use Date*
17. Requested Time*
18. # of Attendees
20. Area Requested*

    1. Commissioners' Public Meeting Room #1 (holds approx 15)
    2. Commissioners' Public Meeting Room #2 (holds approx 15)
    3. Commissioners' Public Meeting Room #3 (holds approx 30)
    4. Courtyard Square
    5. Tour

    Commissioners Public Meeting Room Hours: 8:30 AM - 3:30 PM
22. Activity (Include a brief explanation)*
24. Important: Must review
    View Facility Use Rules & Regulations
25. I have reviewed Rules & Regulations*

    1. Yes
27. Electronic Signature
    Providing a signature indicates: : I have read and understand the Facility Use Application and attached instructions and agree to comply with said instructions and applicable rules, regulations, ordinances and policies covering the use of county properties/facilities. The applicant hereby waives, releases and relieves WESTMORELAND COUNTY, its Commissioners, officers, employees and agents for any and all claims, causes of actions and liability for injury, loss, expense or damage of any kind incurred by applicant, its officers, employees, agents, volunteers, and guests during the use of the facility and agrees further to defend, indemnify and hold the county harmless from any such claims, cause of action and liability for injury, loss expense or damage of any kind incurred by applicant, its officers, employees, agents volunteers and guest during said use arising from such negligent acts or omissions of applicant, its officers, employees, agents, volunteers, and guests as indicated.
29. Electronic Signature of Permit Holder*
30. Date*
    Date
32. Title
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field