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<br />JAN 09 2004 09:47 FR ARTESYN ENGINEERING 612 392 6740 TO 96514298629 <br /> <br />P.02/16 <br /> <br /> <br />tervi[[e <br />~'nEfQ/wllS.."7 <br /> <br />CenterviUe <br />Special Event Permit Application <br /> <br />1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: 2004 Centerville and Lino <br />Lakes Lions Ice Fishing Contest <br /> <br />New Application: _X <br /> <br />Renewal of or Change in Application: <br /> <br />CONTACT PERSON: Greg Kieselhorst <br />TELEPHONE: 612-221-9122 <br /> <br />OR 651-653-1833 <br /> <br />2. IDENTIFYJNG lNFORMATION: <br /> <br />Attach a wrillen communication from the organization(s) in whose name the evenl will be advertised which <br />authorizes you. the applicant. to apply for this special event permil on its/their behalf. <br /> <br />Applicant's Name: _Greg Kieselhorst <br />Address: 7155 Brian Drive Cenlerville. MN 55038 <br />Mailing Address: Same as above <br />Affiliation: Centerville Lions Club <br />Day Phone: _612-221-9122 Evening Phone: <br />Emergency Phone: 612-221-9141 <br /> <br />Title: Lions Secretary <br /> <br />651-653-1833 <br /> <br />3. EVENT PRINCIPALS: <br /> <br />Following, plcase list the namcs. addresses and telephone numbers of all the principals involved in any of the <br />proposed special event. IncIud~ professional event organizers. event pTomotcrs, financial underwriters, commercial <br />sponsors, charitable agcncies for whose benefil the event is being produced, the organization(s) in whose name the <br />event is being advcrtised. and all othe'" administratively, financially and organi7.ationally 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 evenl. <br /> <br />Name: Centerville Lions and Lino Lakes Lions Clubs <br />OrganizationlBusinessl Agencyl Affiliation: <br /> <br />Is this a non-profit organization? <br /> <br />_X_ Yes <br /> <br />No <br /> <br />If )'ou are making application under non-profit stalUs, Droof of non-DTOfil stams must be auached Lo lhis aDDlication <br />'Should be on file with lbe City of Cenler/ille from lhe Minnesota Sccretary of Stale, if nol it's provided. <br /> <br />Mailing Address: Same as above Day <br />Phone: _Same Evening Phone: Same <br />Title and functional responsibility with regard to the event: Centerville Lions Secretary. As part <br />of said duties, event permits and Lion insurance add-ons etc. <br /> <br />Page 1 of 10 <br />