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JAN 26 2004 13:12 FR ARTESYN ENGINEERING 6123926740 TO 96514298629 P.02/11 Centerville Special Event Permit Application 1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: 2004 Festival EventslDance New Application: _X_ Renewal of or Change in Application: CONTACT PERSON: Greg Kieselhors[ TELEPHONE: 651-653-1833 OR 612-221-9122 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 permil on its/their behalf. Applicant's Name: _Greg Kieselhorst Address: 7155 Brian Drive Centerville. MN 55038 Mailing Address: Same Affiliation: Centerville Lions Club Day Phone: _612-221-9122 Evening Phone: Emergency Phone: 612-221-9141 Title: Secretarv 651-653-1833 3. EVENT PRINCIPALS: FoUowing. 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 benefitlhe event is being produced. the organization(s) in whose name the event is being advertised, and all others lldministratively. financially and organizationally involved lIS principals in the production of the proposed special evcnl. Make additional copies of [he following as nceded [0 include as of the principals involved in the proposed special event. Name: Centerville Lions Club OrganizationlBusiness! Agency! Affiliation: Lions International Is this a non-profit organization? ..:x_ Yes No If you are making application under non-profit status, Droor of non-profit ,tatlL' must be attached to this anolicalion Mailing Address: Same Day Phone: _Same Evening Phone: Same Title and functional responsibility with regard to the event: Lions Secretary, as part of said duties permit applications and insurance add-ons etc. Page 1 of 10