2003-09-10 CC Packet - Laserfiche WebLink

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.~ .' Centerville Special Event Permit Application 1. 1~ PlJR!'OSE, AND BRIEF,,' DE~CR!PTION OF EVENT, : ~ ~::e!J;!~~~~~~~ == =ttl:ldt- ~ New Application: /-- , CONTACT ~ON:_ -f1t~L -Z>/~FK. ~ TELEPHONE~V~ -=_q~ op(Id)...c;St/-OIFo' Renewal of or Change in Application: " 2. IDENTIFYING INFORMATION: Attach a written communication from the orvni7J1tion(s) in whose name the event will be advertised which authorizes you, the applicant, to apply for this special event permit on itsItheir behalf -'. Applicant's Name: Address: Mailing Address: Affiliation: Day Phone: Emergency Phone: Title: Evening Phone: 3. EVENT PRINCIPALS: Following, please list the names, addresses and telephone numbers of all the principals involved in any in the proposed special event. Include professional event organizers, event promoters, financial underwriters, commercial sponsors, charitable agencies for whose benefit the event is being produced, the o~7.lrtion(s) in whose name the event is being advertised, and all others administmtively, financially and org;mi7.lrtionally 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: Ce~/fl"rltl!c I.f~S I :5 L P t..rlT11ls OrganizationIBusinessl Agency! Affiliation: 1'"18 this a non~rofit...o.rW'ni7J1t10n? ,/ Yes No If you are making application under non-profit status, Dl'OOf of non-orofit status must be attached to this aonlication Mailing Address: Day Phone: Evening Phone: Title and functional responsibility with regard to the event: Page I of 10