2012-06-06 P & R Packet - Laserfiche WebLink

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Centerville Special Event Permit Application 1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: Festival of Lakes Skate/Run/ Walk New Application: X Renewal of or Change in Application: CONTACT PERSON: Pat Branch, Chair Parks & Recreation Committee TELEPHONE: 703 -501 -6815 OR 2. IDENTIFYING INFORMATION: Attach a written communication from the organization(s) in whose name the event will be advertised which authorizes you, the applicant, to apply for this special event permit on its /their behalf. Applicant's Name: Pat Branch Title: Chair Address: 1618 Hunters Ridge Lane Mailing Address: Same as above Affiliation: Parks & Recreation Committee Chair Day Phone: Same as above Evening Phone: Emergency Phone: 3. EVENT PRINCIPALS: Following, please list the names, addresses and telephone numbers of all the principals involved in any of 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 organization(s) in whose name the event is being advertised, and all others administratively, financially and organizationally 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: Parks & Recreation Committee Organization/Business/Agency/Affiliation: Local Businesses Sponsors Is this a non - profit organization? Yes X No If you are making application under non - profit status, proof of non - profit status must be attached to this application Mailing Address: Day Phone: Evening Phone: Title and functional responsibility with regard to the event: Page 1 of 10