2004-01-28 CC Packet - Laserfiche WebLink

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JAN 25 2004 13:12 FR ARTESYN ENGINEERING 5123925740 TO 95514298529 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 Kieselhorsl TElEPHONE: 651-653-1833 OR 612-221-9122 2. IDENTIFYING INFORMATION: Attach a wrillon communication from the organization(s) in whose name the event will be adveniscd which authorizes you. the applicant. to apply for this special event permil on its/their behalf. Applicant's Name: _Greg Kieselhorsl Address: 7155 Brian Drive Centerville. MN 55038 Mailing Address: Same Affiliation: CenterviUe Lions Club Day Phone: _612-221-9122 Evening Phone: Emergency Phone: _612-221-9141 Title: SecretarY 651-653-1833 3. EVENT PRINCIPALS: FoUowing. please list the names, addresses and lelephone numbers of all the principals invol ved in any of the proposed special event. Include professional ovent organizers, event promoters, financial underwriters, commercial sponsors, oharitable agencies for whose benefit the event is being produced, the organizarion(s) in whose name the evenl is being advertised. and all others administratively. financially and org..uzationally involved as principals in the production of the proposed special event Malee addilional copies of lhe following as needed to include n5 of the principals involved in the proposed special event. Name: Centerville Lions Club OrganizationIBusinesslAgency/Affiliation: Lions International Is this a non-profit organization? ...x_ Yes No If yoU are making application under non-profil slatus, Droof of non-Drofit ,tatus musl be attached to this al)Dlicalion 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