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2. Organization:
4. Address:
6. Representative:*
8. Representative's address:*
10. Room requested:*
11. Date requested:*
13. Purpose of meeting:*
15. Time requested:*
    Example: 10 a.m. - 2 p.m.
17. Phone number:*
18. Email Address:
20. Acceptance of Responsibility
    The undersigned, an authorized representative of the organization, agrees to abide by the Pittsfield Charter Township Building Use Policy and accepts financial responsibility for damage to the facility, costs associated with supervision, or clean-up associated with the organization, and any costs imposed as a result of the failure to return the building key on the next business day.
    
    There are no kitchen facilities for use on the premises. Food and beverages (with the exception of water) are prohibited in Morris Hall at Pittsfield Charter Township Administration Building.
22. Waiver and Release of Liability
    The undersigned, an authorized representative of the organization requesting to use Pittsfield Charter Township facilities, in consideration of Pittsfield Charter Township, authorizing the use of the facilities, hereby releases Pittsfield Charter Township, its administrators, trustees, officials, employees, agents, attorneys, contractors, affiliates, and assigns (releasees) from any and all liability arising out of the use of the premises for any reason whatsoever, and agrees to indemnify releasees from any and all claims of liability or damages which may arise from the use of the premises by members of the organization, its invitees, licensees, or guests.
    
    This release also applies to claims made or asserted as a result of the facility not being available to the organization or individual members, invitees, licensees, or guests. The organization specifically waives any claims against releasees arising from the use of or the inability to use township facilities.
24. Electronic signature:*
    Print your name.
25. Date:*
27. Key number:
28. Date received:
30. Date returned:
31. Issued by:
33. Received by:
35. Costs assessed:
37. Summary of damage / fees assessed:
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit Submit and Print

* indicates a required field