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2. VILLAGE BUILDING FEES & OCCUPANCY LIMITS
4. Auditorium Fees

   $250.00 per day

   $350.00 for 2 consecutive days

   $450.00 for 3 consecutive days

   $50.00 per day for non-profits

5. Conference Room Fees

   $50.00 per day

   $75.00 for 2 consecutive days

   $100.00 for 3 consecutive days

   $25.00 per day for non-profits

6. Occupancy Limits:

   325 | Village Building Auditorium

   40 | Village Conference Room

   Please note, occupancy limit does not represent available seating. 

10. CONTACT INFORMATION
12. Organization/ Group Name*
13. Requester Status*
    -- Select One --Powhatan County GovernmentPowhatan County SchoolNon-profit organizationBusinessPrivate Group (Resident)Private Group (Non-resident)

    Select One

15. Organization Representative*
16. Phone Number*
17. Email*
19. Are you a Powhatan County resident?*
    -- Select One --YesNo
20. Billing Address

    Invoice will be send to this address

24. RESERVATION INFORMATION
26. Facility Requested*
    -- Select One --AuditoriumConference Room
27. Function Type*
    -- Select One --PerformanceRehearsalMeetingConferenceOther
29. Function Date(s)*
    Function Date(s) Start Date

    —

    Function Date(s) End Date
30. Function Time*
    Function Time Start Time

    —

    Function Time End Time
31. Set-up/ Clean-Up Time*
    Set-up/ Clean-Up Time Start Time

    —

    Set-up/ Clean-Up Time End Time

    Set up and clean up hours are included in billing.

33. Please provide a description of your function.*
34. Approximate Attendance*
36. Select all the County services/amenities requested.*

    1. Audio/ visual equipment
    2. Sound Equipment
    3. PA System
    4. On Staff Technician
    5. County Staff
    6. None
37. Select all the equipment/services you will supply*

    1. Sound equipment
    2. PA system
    3. Special lighting
    4. Live entertainment
    5. None
38. What are the power requirements of your supplied sound equipment?
40. Provide a description or requested quantity for each county service needed above. *
44. LIABILITY INSURANCE INFORMATION

    All events that occur on County property must have at least $1 Million of liability coverage and the County must be listed as an additionally insured party on the policy.

    The County does not insure private party rentals. GatherGuard is a program through the County’s insurance provider, VACorp, that covers events held by third parties on County property with $1 million of protection.  Renters can purchase this coverage and depending on the type of event, the cost can be as little as $100.  

    https://www.vacorp.org/coverage/tulip/

    The certificate must read as follows:

    The County of Powhatan, 3834 Old Buckingham Road, Powhatan, VA 23139

    Under the description part of the insurance it must read: 

    “The County of Powhatan, its officers, officials and employees are named as additional insured.” 

    Make sure that the box listed as “Additionally Insured” is checked. It will be sent back if not.

46. Do you have public liability and property damage insurance in an amount not less than $1,000,000 per occurrence? *
    -- Select One --YesNoNA
47. Liability Insurance

    If you have liability insurance on file, you may upload it here.

49. LIABILITY & INDEMNIFICATION

    I represent the above-named organization, assume full responsibility for the above-requested facility and declare this activity to be in compliance with County regulations, fire codes and applicable laws.

51. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
53. Electronic Signature
55. Thank you for your request!

    A member from our team will follow up with you within the next 3-5 business days. If you do not hear back from a member of our team, please call us at (804) 598-5781.

Leave This Blank:


57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit

* indicates a required field