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<br />Centerville
<br />Special Event Permit Application
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<br />1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: (In n... Q L
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<br />New Application:
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<br />t/
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<br />Renewal of or Change in Application:
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<br />CONTACT PERSON: t\~d.{e\~ ~\C:"'.n I f"t"s..h"('~\. f""""rc\,,^,,,'\-':'n.,.
<br />TELEPHONE: C\S2.-C\'"'L' -<''-\3\ OR f=r..,......... F,J,.l.fu,c'\.~
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<br />2. IDENTIFYING INFORMATION:
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<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 pennit on its/their behalf.
<br />
<br />Applicant's Name: Qnc!..rt'w ~eL<:~pr Title: '1',<.-.,,_ ('",<>{'d:"C\~)'1..
<br />Address: (. '1<15 u,M.>Cv,\\.... Qr\. ~ '\c~"3 ~tH aL 'Sk...
<br />Mailing Address: q... .<:OK-! ~;J;:J;..,l 0...1.
<br />Affiliation: Mo... 'b",
<br />Day Phone: 0,5'2..- <::\'1_'\- <''-\3 \ Evening Phone:
<br />Emergency Phone:
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<br />3. EVENT PRINCIPALS:
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<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 undenvriters, 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: I(="(.~,"", f\~1':)~o\.L
<br />OrganizationIBusiness/ Agency/Affiliation:
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<br />Is this a non-profit organization? v Yes
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<br />No
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<br />If you are making application under non-profit status, proof of non-profit status must be attached to this application
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<br />Mailing Address: /ci&. Gt.,~,4 ~ G!...d
<br />Day Phone: ~S\- '-\ 1...<'1_1 <'I~"" Evening Phone:
<br />Title and functional responsibility with regard to the event:
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