Town of Cummington

Application for permission to use Community House Facilities

Name: Telephone:

Address:

Group/Organization:

Date(s) and Times requested:

Number attending (approximate):

Type of space requested (i.e. Auditorium, Conference Room (in back), kitchen, Library, or Selectmen)

Reason for use of space:

Amount of fee enclosed:

Is Certificate of Insurance enclosed?

Please note all scheduling is done on first come - first served basis upon receipt of fee.

All groups will be required to furnish a Certificate of Insurance naming the Town of Cummington as Loss Payee for the duration of the event.

See attached fee schedule and rules for Community House use.

Please return completed application along with fee to:

Community House Coordinator

Cummington Community House

P.O. Box 128, Main Street,

Cummington, MA 01026