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Centerville Special Event Permit Application—on Private Property 1. TITLE,PURPOSE,AND BRIEF DESCRIP�jiON OF EVENT: St. Genevieve Parish Picnic � , /lo New Application: X Renewal of or Change in Application: Has this event been held in the past? FV] Yes n No If so, when? annually CONTACT PERSON: Susie Irlbeck TELEPHONE: 651-4294937 OR EMAIL: sirlbeck(ausfamily.net 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: Susie Irlbeck Title: business administrator Address: 7087 Goiffon Rd Mailing Address: 7087 Goiffon Rd Centerville MN 55038 Affiliation: church Day Phone: 651-429-7937 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: Fr. Greg Esty,pastor Organization/Business/Agency/Affiliation: Church of St. Genevieve Is this a non-profit organization? ✓ Yes No If you are making application under non-profit status,proof of non-profit status must be attached to this application Mailing Address: 7087 Goiffon Rd Centerville MN 55038 Day Phone: 651-429-7937 Evening Phone: Title and functional responsibility with regard to the event: Page 1 of 5 P21