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<br />~ JA~ 09 2004 09:47 FR ARTESYN ENGINEERING 612 392 6740 TO 96514298629 <br /> <br />P.02/16 <br /> <br />a tervil{e <br /> <br />" "fJ,nff"f..f'''' <br /> <br />Centerville <br />Special EventPeruUtApplication <br /> <br />1. TITLE, PURPOSE, AND BRIEF DESCRlPTION OF EVENT: 2004 Centerville and Lino <br />Lakes Lionslce 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. IDENTIFYING INFORMATION: <br /> <br />Attach a wrillen communication from the organization(s) in whose name the evenl will be advertised which <br />aUlhorizes you, the applicant, to apply for this special evenl permit on ilSltheir behalf. <br /> <br />AppJicam's Name: _Greg Kieselhorst <br />Address: 7155 Brian Drive Centerville. 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, please list the names, addresses and telephone numbers of all the principals involved in any of the <br />proposed special event. Include professional evenl organizers. event promolers, financial underwriters, commercial <br />sponsors, charitable agencies for whose benefil the event is being produced, the organization(s) in whose name the <br />event is being advertised, and all others 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 incl ude as of the <br />principals involved in the proposed special evenL <br /> <br />~ <br /> <br />Name: Centerville Lions and Lino Lakes Lions Clubs <br />OrganizationlBusiness/Agencyl Affiliation: <br /> <br />Is this a non-profit organization? <br /> <br />_x_ Yes <br /> <br />No <br /> <br />If you are making application under non-prollt status, Droof of non-Drolll'tams musl be allached 10 Ihis aDDHeation <br />'Should be on Ille with the City of CenterViIle from the Minnesota Secretary of Stale, if nOI ii'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 />