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12/20/2010 10:03 _ 8133223589 PASCOPAWS PAGE 02/05 <br /> FART III. A g ,PLIcANT INFOMAT!N <br /> Name of Organization: s � Y bi V G rtr <br /> Applicant muss be a not-for-profit entity, register to do business in the State of Florida <br /> Contact person: D AV 1 b & HPtY <br /> ess: Pa (o [ t / 3353? 35 3 / <br /> Mailing adder <br /> Phone nurnber (including area code): ( T 1 - 7 83 73 ?' <br /> Alternate phone number (0) 3) S 9' 8 ‘ / <br /> Fax number (includin area code): ! 3 7 83 2- 7 <br /> ss:_ <br /> Email addre@ -- S I<.'r J) i " E.C_1 , Gotli <br /> Date incorporated: <br /> Current corporate status: (Circle One) .Active Inactive <br /> Employer Identification Number (ExN): <br /> PART II EIMUNSUBita <br /> Do you have any co- sponsors for the event ?: , 7No Yes <br /> • If yes, please list: <br /> Will an admission fee be charged to attend this event ?: $No Yes <br /> If yes, how much will the fee be ?: <br /> Please note, an application for any level of City subsidy of a spec ; I ' ' 1 ' ed with the <br /> City Manager by June 1 for events occurring during the fol r tober 1- <br /> September 30) <br /> Approve . !C . day of 2 O1L. <br /> By Afr7 <br /> ,a <br /> �rou ► L cs R m Director of Development <br /> rim Ex+'( .6�'K� `�, 1. p u :A Authorized Signature <br /> per. i-;�rr. $f. SJe.c Site Plan Review Fee Paid <br /> • <br /> rau,�c. C . copi Fri Date/� .... - ... Amount it __....__. <br /> Lt eL <br /> 2 <br />