Laserfiche WebLink
a 4 ` tervitte <br /> EsmNLrfiedLW Centerville <br /> Special Event Permit Application <br /> 1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: 2011 Centerville Lions <br /> Haunted House <br /> New Application: _ X Renewal of or Change in Application: <br /> CONTACT PERSON: Greg Kieselhorst/Terry Sweeney <br /> TELEPHONE: 612- 221 -9122 OR 651- 270 -2010 <br /> 2. IDENTIFYING INFORMATION: <br /> Attach a written communication from the organization(s) in whose name the event will be advertised which <br /> authorizes you, the applicant, to apply for this special event permit on its/their behalf. <br /> Applicant's Name: _Greg Kieselhorst Title: Lion Secretary <br /> Address: 7155 Brian Drive Centerville, MN 55038 <br /> Mailing Address: Same <br /> Affiliation: Centerville Lions Club <br /> Day Phone: _952- 361 -4159 Evening Phone: 612 - 221 -9122 <br /> Emergency Phone: _ 612 -221 -9141 <br /> 3. EVENT PRINCIPALS: <br /> Following, please list the names, addresses and telephone numbers of all the principals involved in any of the <br /> proposed special event. Include professional event organizers, event promoters, financial underwriters, commercial <br /> sponsors, charitable agencies for whose benefit the event is being produced, the organization(s) in whose name the <br /> event is being advertised, and all others administratively, financially and organizationally involved as principals in <br /> the production of the proposed special event. Make additional copies of the following as needed to include as of the <br /> principals involved in the proposed special event. <br /> Name: Centerville Lions Club <br /> Organization/Business /Agency. /Affiliation: Lions International <br /> Is this a non -profit organization? _X Yes No <br /> If you are making application under non - profit status, proof of non - Profit status must be attached to this application <br /> Non -Profit status should be on file from past events, otherwise it will be provided. <br /> Mailing Address: Same <br /> Day Phone: _Same Evening Phone: Same <br /> Title and functional responsibility with regard to the event: Lion Secretary, as part of said duties <br /> permit applications and insurance add -ons etc. <br /> Page 1of10 <br /> 1 1 <br />