2011-07-06 P & R Packet - Laserfiche WebLink

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- , � �'� `' �.. ervi��Ce �� ' Centerville Special Event Permit Application 1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: 2011 "Fete des Lacs" New Application: X Renewal of or Change in Application: CONTACT PERSON: Greg Kieselhorst TELEPHONE: 612-221-9122 OR 612-221-9141 2. IDENTIFYING INFORMATION: Attach a written communication from the organization(s) in whose name the event will be advertised which authorizes you, the applicant, to apply for this special event permit on its/their behalf. Applicant's Name: Greg Kieselhorst Title: Lion Secretarv Address: 7155 Brian Drive Centerville. MN 55038 Mailing Address: Same Affiliation: Centerville Lions Club Day Phone: 612-221-9122 Evening Phone: 612-221-9122 Emergency Phone: 612-221-9141 3. EVENT PRINCIPALS: Following, please list the names, addresses and telephone numbers of all the principals involved in any of the proposed special event. Include professional event organizers, event promoters, financial underwriters, commercial I sponsors, charitable agencies for whose benefit the event is being produced, the organization(s) in whose name the event is being advertised, and all others administratively, financially and organizationally involved as principals in the production of the proposed special event. Make additional copies of the following as needed to include as of the principals involved in the proposed special event. Name: Centerville Lions Club OrganizationlBusiness/Agency/Affiliation: Lions International Is this a non-profit arganization? X Yes No If you are making application under non-profit status, uroof of non-profit status must be attached to this application Non-Profit status should be on file, otherwise it will be provided. Mailing Address: Same Day Phone: Same Evening Phone: Same Title and functional responsibility with regard to the event: Lions Secretary, as part of said duties pernut applications and insurance add-ons etc. Page 1 of 10