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2. Instructions:
   This application must be completed in its entirety. Payment is due within 48 hours of submitting an online application or the reservation will be canceled, unless arrangements have been made and authorized by Town staff. Payments can be made at Town Hall., 221 S. Nursery Ave. The address to the Purcellville Train Station is, 200 N. 21st Street, Purcellville, VA 20132.
4. Non-Profit Group or Organization Name:*
6. Room(s) Requested:*

   1. Large Room
   2. Small Room
   3. Both Rooms
8. Number of Hours Requested and Costs for Use:

   1. $160 - Full Day Use (over 6 hours)
   2. $120 - Half Day Use (6 hours)
   3. $80 - Four Hour Block
   4. $60 - Two Hour Block
   5. $40 - One Hour Block
10. Non-Profit Cost for Use:

    *Must submit IRS letter with application

    1. $20 per Two Hour Block
    2. $40 per Four Hour Block
11. IRS Letter (if applicable):
13. Applicant/Primary Contact Name*
    (If non-profit, must be a board member ond authorized to reserve under the 501(c)(3) as the non-profit takes full responsibility for the reservation.)
15. Full Address:*
17. Phone Number:*
19. Email Address:*
21. Will food and/or drinks be served? (No alcoholic beverages permitted at any time.)*

    1. Yes
    2. No

    *I understand that I must take my trash with me when I leave the Train Station or will be charged a $75 cleaning fee.
23. For Multi-Day Rentals, will you request to leave items in the facility overnight?

    1. Yes
    2. No
25. Description of Program:*
27. Approximate Number of Attendees:*
29. I understand that the total capacity for the building is 99 people. Should this capacity be exceeded, the meeting/event may be canceled immediately due to capacity limitations set forth by the Loudoun County Fire Marshall's Office*

    1. I Agree
31. Requested Dates and Times*
    Requested Dates and Times Start Date

    Requested Dates and Times Start Time

    —

    Requested Dates and Times End Date

    Requested Dates and Times End Time
    Times should include set-up/clean-up time. For multi-day rentals, no items may be left in the facility overnight without prior approval from staff.
33. Additional Date/Time:
    Additional Date/Time: Start Date

    Additional Date/Time: Start Time

    —

    Additional Date/Time: End Date

    Additional Date/Time: End Time
35. Additional Date/Time:
    Additional Date/Time: Start Date

    Additional Date/Time: Start Time

    —

    Additional Date/Time: End Date

    Additional Date/Time: End Time
37. If you have a series of dates and times, (more than 3) you may enter them here:
39. RULES, REGULATIONS AND INFORMATION FOR USE OF THE CONFERENCE ROOMS AT THE PURCELLVILLE TRAIN STATION
41. I understand and confirm that my reservation time includes set up and clean up time.*

    1. I Agree
43. I understand that I must clean up the area and remove all of my items, including trash, at the end of my rental period, or I may be charged a $75 cleaning fee.*

    1. I Agree
45. I understand the keyless entry system will be activated 15 mins. prior to my rental time and will automatically lock at the end of my rental. If I encounter any issues, I will send an email to facilities@purcellvilleva.gov.*

    1. I Agree
47. I will ensure that, upon my departure, the building will be secured, all lights are turned off, and windows are closed.*

    1. I Agree
49. I agree that I will not hang signs on the wall, on glass or display on the property without prior permission from Town staff.*

    1. I Agree
51. I will not rearrange the furniture without prior permission from Town staff. If granted, I agree to return the furniture to its original location at the end of my rental.*

    1. I Agree
53. I understand that food and drinks are not permitted in the Train Station without prior approval from Town staff. All trash must be removed upon leaving the Train Station. There is a full size refrigerator and freezer for use but no cooking facilities.*

    1. I Agree
55. I understand that smoking is not permitted in the Train Station.*

    1. I Agree
57. I understand that use of the Train Station shall be automatically canceled on any day that the Town government implements the Emergency Weather Plan due to inclement weather or other emergencies. In such an event, notice of cancellation will not be provided (although we do post on our Facebook page and website) and users shall be solely responsible for notifying their participants.*

    1. I Agree
59. I understand that if it is necessary for the Town Council, Town committees or staff to conduct government business at the same time as an event is scheduled, the Town has priority over the use of the facility.*

    1. I Agree
61. I agree that I will not sell items, raffle or other types of fundraising activities without a Town of Purcellville business license.*

    1. I Agree
63. I understand that no pets are permitted inside the Train Station.*

    1. I Agree
65. I understand that the Town does not supply additional equipment for my meeting (extra tables/chairs).*

    1. I Agree
67. I understand the property is rented "as is" and there is a large monitor for use with connection through a 20 ft. HDMI cable. WiFi is available ( password: 200N21stST).*

    1. I Agree
69. I understand that the Town reserves the right to change/update "per use" fees.*

    1. I Agree
71. I understand there are two existing restrooms at the facility. One restroom is available from the interior for my use and the other remains available for exterior general public use only.*

    1. I Agree
73. I understand that I may not set up the day before my event unless I have reserved and paid for two days, and authorization has been given by Town staff to leave items in the facility overnight. *

    1. I Agree
75. If I have a multi-day rental, I will not leave materals/items in the Train Station overnight without prior authorization from Town staff.*

    1. I Agree
77. Comments/Notes/Requests:
79. Rules, Regulations and Information for Use of the Conference Rooms at the Train Station
    Rules, Regulations and Information for Use
81. AUTHORIZATION AND IDEMINIFICATION:
83. The individual signing/submitting verifies that he or she is legally authorized to bind and act on behalf of the applicant/group. The applicant/group, including all of the applicant/group’s officers, employees, members, agents, and other representatives utilizing the Train Station, hereby agree to hold harmless and to indemnify, defend and protect the Town of Purcellville and its Council Members, officials, employees, agents, volunteers and other representatives against any and all claims, losses, damages and liabilities whatsoever to persons or property incurred resulting from or caused by, directly or indirectly, the actions and/or inaction of the applicant/group, including, but not limited to, the applicant’s/group’s installation, removal, maintenance, occupancy, and/or use of the Train Station premises or any part thereof. This indemnification shall extend to all claims for death or injury to persons and/or damage to property and to the payment of all legal expenses (including reasonable attorney’s fees) incurred defending the Town of Purcellville from such claims. The applicant/group agrees that any damage to the property of the Town of Purcellville, including, but not limited to the Train Station, and any related equipment or property, due to the actions or inaction of the applicant/group will result in a financial obligation of the applicant/group to the Town of Purcellville to replace, repair or otherwise correct such damage. I agree that all representatives acting on the applicant’s/group’s behalf for any matter pertaining to the use of the Train Station will be subject to all rules herein as well as any rules provided to the applicant/group prior to and/or during the use of the Train Station.*

    1. I Agree
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