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f .50 <br /> RE Centerville <br /> Special Event Permit Application <br /> 1. <br /> TITLE;P SE,AND BRIEF DESCHJPTI N,OF Ev�NT: rAj r� 1 1 Y <br /> ail <br /> n n w or\ , SUMA. bid Ku►) <br /> New Application: Renewal of or Change in Application: <br /> CONTACT PERSONja n& <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 <br /> for this special event permit on its/their behalf. <br /> Applicant's Name: J#-n& bo ert Title: No <br /> Address: 935110 <br /> Mailing Addss: <br /> Affiliation: Trt -rN:s S <br /> Day Phone: Ilr f Evening Phone: <br /> Emergency Phone: VIA 10 5 U(ps <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 /> Name: J UCU i LVl ()Sitnaor- <br /> OrganizationBusiness/Agency/Affiliation: I S <br /> Is this a non-profit organization? Yes No <br /> If you are making applicationunder non-profit status,proof of non-profit status must be attached to this application <br /> Mailing Address: s`'La' as a6v�p, <br /> Day Phone: Evening Phone: <br /> Title and functional responsibility with regard to the event: <br /> Page 1 of 10 <br /> P27 <br />