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6 m . rI ft e Centerville <br />Special Event Permit Application <br />TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: 2012 Centerville Lions Ice <br />Fishing Contest on Centerville Lake; Free Kids Airplane Rides with EAA Members out of <br />Benson Airport, Limited to 50 -100 Kids, on Centerville and or Peltier Lake, weather permitting <br />for both Events. <br />New Application: _X <br />Renewal of or Change in Application: <br />CONTACT PERSON: Greg Kieselhorst <br />TELEPHONE: 612 - 221 -9122 OR <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 as above <br />Affiliation: Centerville Lions Club <br />Day Phone: _612- 221 -9122 Evening Phone: Same <br />Emergency Phone: 612 - 221 -9141 <br />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: Volunteer Organization <br />Is this a non -profit organization? _X_ Yes <br />ILTI <br />If you are making application under non - profit status, proof of non -profit status must be attached to this applicati on <br />*Should be on file with the City of Centerville from the Minnesota Secretary of State, if not it will be provided. <br />Mailing Address: Same as above Day <br />Phone: _Same Evening Phone: Same <br />Title and functional responsibility with regard to the event: Centerville Lions Secretary. <br />Event Permits and Lion Insurance add -ons etc. <br />Page 1 of 10 <br />15 <br />