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<br />---,-l' <br />{ <br /> <br />, <br /> <br />~ <br /> <br /> <br />Centerville <br />Special Event Permit App6eation <br /> <br />1. <br /> <br />4~S~B1;DE~OF~T~l'#;h~ <br /> <br />New Application: V Renewal of or Change in Application: <br /> <br />CONTACT PERSON: f\,u~!~A f\/~v~. ( <br />. TELEPHONE: OR <br /> <br />IRS"' '-'1{) 1.-oS-~ <br />(~~ I rZ- 71--(.,'f 'll/l <br /> <br />2. IDENTIFYING INFORMA nON: <br /> <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 for this special event permit on its/their behalf. <br /> <br />I <br /> <br />Applicant's N"""'~ (.i S5... N", V .-.c:t..' <br />Address: ~ ou.-v- f ~ <br />Mailing Address: <br />Affiliation: <br />Day Phone: US-~Dl-D~ <br />Emergency Phone: <br /> <br />Title: <br /> <br />~.A'-(-1 ~ <br /> <br />Evening Phone: <br /> <br />3. EVENT PRINCIPALS: <br /> <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 /> <br />Name: _~ ",,- ~tL; <br />Organization/Business/ Agency/Affiliation: <br /> <br />Is this a non-profit organization? <br /> <br />Yes <br /> <br />No <br /> <br />If you are making application under non-profit status, proof of non-profit status must be attached to this apnlication <br /> <br />Mailing Address: <br />Day Phone: Evening Phone: <br />Title and functional responsibility with regard to the event: <br /> <br />Page 1 of 10 <br /> <br />33~ <br />