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7 f t I`. R Centerville Special Event Permit Application 1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: Hmonq Flaq Football Tournament to help fundraise and pay off the damaqe that was occured at the Centerville Lamotte Memorial Park in June of 2013 New Application: Yes Renewal of or Change in Application: CONTACT PERSON: Tenq Moua TELEPHONE: (763) 398 - 9191 O 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: Tenq Moua Title: Address: 6641 Jersey Ave N, Brooklyn Park, MN 55428 Mailing Address: 6641 Jersey Ave N, Brooklyn Park, MN 55428 Affiliation: Day Phone: (763) 398 - 9191 Evening Phone: Emergency Phone: (763) 398 - 9191 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: P 1 G E —'ucl OrganizationB iness /Agency /Affiliation: - I r, 4 I -4 cjA Is this a non -profit organization? Yes No If you are making application under non -profit status, proof of nonprofit status must be attached to this application Mailing Address: A:XX I 'LSr Day Phone: - — S \�N Evening Phone: X61 Title and functional responsibility with regard to the event: Page 1 of 10 67