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' terodfe <br /> EfW ffz&WM57 Centerville <br /> Special Event Permit Application <br /> 1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: ? _ q S )e r <br /> New Application: Renewal of or Change in Application: <br /> CONTACT PERSON: '4T- 04 a' � <br /> W <br /> TELEPHONE: 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 . <br /> u r this special event permit on its /their behalf <br /> Applicant's Name: j c)A ej Cp, etpJl' Title: <br /> Address: — 1 (2A <br /> Mailing Address: <br /> Affiliation: <br /> Day Phone: (,:sk . �'2 Ep , _Evening Phone: to w 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 /> m <br /> Nae: kL L �Vt) o Nn Ri <br /> Organization/Business /Agency /Affiliation: <br /> Is this a non - profit organization? VZYes No <br /> If you are making application under non-profit status, proof of non profit status must be attached to! his ap plication <br /> Mailing Address: la — 2 j <br /> 'o I 1 N g N <br /> r <br /> Day Phone: [ _ 0 3 4 - Evening Phone: <br /> Title and functional responsibility with regard to the event: CIS ?-.p <br /> Page 1 of 10 <br /> 127 <br />