2009-08-26 CC Agenda - Laserfiche WebLink

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(i,;.,~ Centerville Special Event Permit Application 1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: 2009 Centerville Lion Haunted House New Application: _X_ Renewal of or Change in Application: CONTACT PERSON: Greg Kieselhorstfferry Sweeney TELEPHONE: 612-221-9122 OR 651-270-2010 2. IDENTIFYlNGlNFORMATION: Attach a written communication from the organization(s) io whose name the event will be advertised which authorizes you, the applicant, to apply for this special event permit 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: _952-361-4159 Evening Phone: Emergency Phone: 612-221-9141 Title: Lion Secretarv 612-221-9122 3. EVENT PRiNCIPALS: F ollowiog, please list the names, addresses and telephone numbers of all the priocipals iovolved io any of the proposed special event. Include professional event organizers, event promoters, financial underwriters, commercial sponsors, charitable agencies for whose benefit the event is being produced, the organization(s) io whose name the event is beiog advertised, and all others admioistratively, financially and organizationally iovolved as priocipals io the production of the proposed special event. Make additional copies of the followiog as needed to ioclude as of the priocipals iovolved in the proposed special event. Name: Centerville Lions Club Organization/Business/ Agency! Affiliation: Lions International Is this a non-profit organization? X Yes -- No If you are makiog application under non-profit status, oroof of non-oroftt status must be attached to this aoolication Non-Profit status should be on file from past events, otherwise it will be provided. Mailing Address: Same Day Phone: _Same Evening Phone: Same Title and functional responsibility with regard to the event: Lion Secretary, as part of said duties permit applications and insurance add-ons etc. Page 1 oflO