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k <br /> A <br /> Centerville <br /> Special Event Permit Application <br /> 1. TI LE;PWSE,AND BRIEF DESCRIPTIQN,OF EVENT: �y rS t Y <br /> 011 r)ashlQh SWIM, 21141 KLtn <br /> New Application: Renewal of orC <br /> hange in Application: <br /> CONTACT PERSON n PK"t 051 "f� A <br /> P - 1 1 (01 <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 1 for this special event permit on its/their behalf. <br /> Applicant's Name: jQ�i SJR e(t Title: Qeb No r� <br /> Address: ( I <br /> Mailing Address: <br /> Affiliation: `, rl -rNS S <br /> Day Phone: I gal 4Q: r, L C (Q—Evening Phone: <br /> Emergency Phone: VIA 102) 9U(05: <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 <br /> �inthe proposed special event. <br /> NamVe: u6 , �i c v-1 L csitn d o r-( <br /> Organization/B Try S <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: SAJ)AL as a6V4,, <br /> Day Phone: Evening Phone: <br /> Title and functional responsibility with regard to the event: <br /> Page 1 of 10 <br />