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2. Applicant Details
4. First Name*
5. Last Name*
7. Address1*
9. Address2*
11. City*
12. State*
13. Zip*
15. Phone Number*
16. Email Address*
18. Meeting Details
20. Meeting Date Requested*
21. Meeting Start Time*
22. Meeting End Time*
24. Organization Name
26. Event Description*
27. Number of Attendees
29. Public Safety Station Requested
    -- Select One --North County Fire & Rescue Station #1Mt. Pleasant Fire & Rescue Station #6Bent Mountain Fire & Rescue Station #8Fort Lewis Fire & Rescue Station #9Back Creek Fire & Rescue Station #11

    Choose a location from the drop down list above.
31. Authorization
33. By submitting this online application I am certifying that I am an authorized representative of the organization named above. I have read and agree to comply with the regulations set forth in the Roanoke County Fire & Rescue Policy regarding Use of Fire Station Rooms, and agree to comply with such. I acknowledge that by using the room, I assume responsibility for any damage to the room or its contents, and will report such damage to County Fire & Rescue staff. I agree to indemnify and hold harmless Roanoke County and its employees from any and all claims for damages or injuries arising out of the use of the room. I shall be responsible for assuring that the room is left in the same condition in which it was found.
35. Signature
    Enter full name in the box above.
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field