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enterviik <br /> r areigesv Centerville <br /> Special Event Permit Application <br /> 1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: 212 Div Ds14 <br /> New Application: Renewal of or Change in Application: 77 <br /> CONTACT PERSON: 1\11P'C2)!— c E L <br /> TELEPHONE: 5U1 _ (;-k - 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: M0,V4 t Title: WES 11Q-dc <br /> Address: k?�-k' -\ 1 — t PXI S-} ■F c( SS 0SM <br /> Mailing Address: 1 - \2\ S u f� r•-) CIM 5 3 <br /> Affiliation: <br /> Day Phone: SD1 - 61-tot - 7,3 L Z. Evening Phone: 3 7- (, y -,.2 P <br /> Emergency Phone: <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: w.. 044,-Ark _ E c � <br /> Organization/Business /Agency /Affiliation:e.►...e t^ n <br /> Is this a non - profit organization? Yes No <br /> If you are making application under non - profit status, proof of non - profit status must be attached to this application <br /> Mailing Address: <br /> Day Phone: Evening Phone: <br /> Title and functional responsibility with regard to the event: \I ,r,. ciw - ,,r - k <br /> Page 1 of 10 <br />