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<br />a teroi!fe <br /> <br />'" 'Estaf{isfm{ 1&57 <br /> <br />Centerville <br />Special Event Permit Application <br /> <br />1. TITLE, PUjU>OSE, AND BRIEF DESCRIPTION OF EVENT: i?G~~p I -r ~(I <br />~i- OAt H4//fAJ PAMlvg. <br /> <br />New Application: <br /> <br /> <br />Renewal of or Change in Application: <br /> <br />CONTACT PERSON: <br />TELEPHONE: S .; <br /> <br />2. IDENTIFYING INFORMATION: <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 />Applicant's Name: <br />Address: <br />Mailing Address: <br />Affiliation: <br />Day Phone: <br />Emergency Phone: <br /> <br />Title: <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, fmancial 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: <br />Organization/Business/ Agency/Affiliation: <br /> <br />Is this a non-profit organization? <br /> <br />Yes <br /> <br />-X- No <br /> <br />If you are making application under non-profit status, proof of non-profit status must be attached to this application <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 />3D <br />