Contact InformationPlease provide a complete address, including street, city, state and zip code. Name * Address 1 * Address 2 City * State * Zip Code * Phone * Fax Email * Event Information Title of Event Date * Please enter date of requested usage. MM/DD/YYYY Beginning Time * 121234567891011 : 0030 AMPM Ending Time * 121234567891011 : 0030 AMPM Type of organization requesting usage. * Private Governmental Educational Institution Profit Non-profit Religious OtherIf other, please specify in comments section below. Submitting Entity * If you are submitting this proposal on behalf of any entity other than yourself as an individual, please type your name and position with the organization above. If you are submitting this on behalf of yourself as an individual, please type your name and the word “individually†above. By typing your name and position, you are electronically signing this form on behalf of the organization and representing that you have the authority to submit this form and to bind the organization to the terms stated on this form. Rooms Requested: * Williamsport: Sullivan A (Medium Group: Front - capacity 10-24) Sullivan B (Medium Group: Front - capacity 10-24) Tioga A (Large Group: Front - capacity 30-35) Tioga B (Large Group: Back - capacity 30-35) Tioga C (Medium Group: - capacity 20-30) Lycoming Conference Room (Upstairs - capacity 12-15) Bradford Conference Room (capacity 10) IT Conference Room (Upstairs - 8am-4pm - capacity 10) Goodman Conference Room (Upstairs - capacity 12) Canton: Canton Board Room Canton Zoom Room A (capacity 24 people) Canton Zoom Room B (capacity 24 people)Be sure to select all rooms requested. How many participants are you expecting for this event? * 5-10 11 - 20 21 - 30 31 - 40 > 40 What type of equipment will be needed during the time of usage? LCD Projector/TV Laptop Otherif other, please specify in the comments section below. Comments Will refreshments be served at this event? * Please Select Yes No If yes, please move on to the next question. Who will be responsible for providing the refreshments for this event? Caterer Presenter bringing refreshments. Coffee requested. Other Type of Activity * Meeting Training Presentation Admission fees for participants. * Please Select Yes No If yes, please provide the amount charged per person in the space below. Admission Fee Amount Does your organization have liability insurance? * Please Select Yes No Insurance InformationPlease provide the liability carrier information below. Carrier Name Contact Address Phone Policy Number Hold Harmless AgreementThe organization or individual submitting this request hereby agrees to indemnify, defend, and hold harmless BLaST Intermediate Unit 17, and any director, officer, agent, or employee of BLaST Intermediate Unit 17 against all claims, damages, losses, or penalties that result from the acts or omissions of the employee or agents of the applicant or from the use being made of the facilities. reCAPTCHA If you are human, leave this field blank.