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4 <br />I ame o organization mate aian'% exempt number <br />nt�Li� <br />------- ----------- 7--= <br />Address <br />X849 Cent ill o <br />city <br />t d <br />Statealp <br />I <br />Conde <br />. <br />ing ppltOn <br />'f e 0='er= <br />meD Horne phone <br />Th 9________ <br />_ <br />husiine�ssph <br />-� -7 <br />2=.: m 9 <br />Date(s) of event <br />G -29-2017 <br />Type of oirga°nrni" adoin <br />Club I Charitable <br />[.....� Religious thernon-ipr <br />fut <br />Organization officer's name <br />CityState <br />iip Cede <br />Organizationofficer's nar ne <br />City <br />tate <br />flip Cede <br />t <br />_ <br />Cent til <br />Organization officer°.s mare <br />City <br />___ <br />StateZip <br />Cede <br />� <br />Organization offiiceir"s name <br />city <br />State <br />alp Code <br />mmmm" <br />Location where permit will be used. If an outdoor area, describe. <br />6995 Centerville Road, St. Genevieve's Community ParishCenter <br />RiChe applicant will <br />Christensen Group r 1, i, 0 <br />APPROVAL <br />«> .r <br />Fee r ount <br />date Fee Paid <br />Date Approv <br />Per Dat[late <br />City cnr Cure E-rtnnai dress <br />r <br />eventCLERKS NOTICE. Submit this form to Alcohol and Gambling Enforcement Division 30 days prior to <br />