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t eriterviffe <br /> Established lac Centerville <br /> Special Event Permit Application <br /> 1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: 63-r re r LA <br /> New Application: ,�; Renewal of or Change in Application: <br /> CONTACT PERSON: �J 1-7 <br /> TELEPHONE: (,,S Q y� yo2 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: Jb f-i ' ccu , Title: <br /> Address: - 7 1 2-9 2c 1 /h-e RJR <br /> Mailing Address: C v + / t , , /�h n/- ,337,3 d <br /> Affiliation: <br /> Day Phone: MUM- Evening Phone: , 121Marlittar <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. II __ <br /> Name: pt (ND L �� iU��► ' N <br /> Organization/Business /Agency /Affiliation: ' A 1 _ 1, va <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: Evenin g Phone: <br /> Title and functional responsibility with regard to the event: <br /> Page 1 of 10 <br />