APPLICATION FOR A (CITY/COUNTY)

SEXUALLY ORIENTED BUSINESS EMPLOYEE LICENSE

*Application received on the date stamped above.

*Application was: (a) hand delivered _______

(b) delivered by cert. mail _______

*Application logged in by: ________________________

_____New _____Renewal

*EXPIRATION DATE: _________________________

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Section _____ of the (City/County) Sexually Oriented Business Ordinance states that the Director shall revoke a license if he determines that "a licensee gave false or misleading information in the material submitted" during the application process.

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Applications for an employee license to work and/or perform services in a sexually oriented business, whether original or renewal, must be made to the Director by the person to whom the employee license shall issue. Each application for an employee license shall be accompanied by payment of the application fee in full. Application forms shall be supplied by the Director. Applications must be submitted to the office of the Director or Director's designee during regular working hours.

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SECTION A

1. Applicant's Name ________________________________________________________

2. Applicant's "stage" names and/or aliases ______________________________________

3. Applicant's Age ________ Date and Place of Birth ______________________________

Height _________ Weight _________ Hair Color ___________ Eye Color____________

4. Present Address of Applicant ________________________________________________

Present Telephone # _______________________________________________________

5. Present business address and phone # _________________________________________

6. Applicant's Date, issuing state, and number of photo driver's license, or other state issued identification card information

_______________________________________________________________________

7. Applicant's Social Security Number __________________________________________

SECTION B

1. A color photograph of the applicant clearly showing the applicant's face, and the applicant's fingerprints on a form provided by the sheriff's department must accompany this application. Any fees for the photographs and fingerprints shall be paid by the applicant. Have these been attached? _____________

2. A statement detailing the license history of the applicant for the five (5) years immediately preceding the date of the filing of the application, including whether such applicant, in this or any other city, county, state, or country, has ever had any license, permit, or authorization to do business denied, revoked, or suspended. In the event of any such denial, revocation, or suspension, state the name(s) under which the license was sought and/or issued, the name(s) of the issuing or denying jurisdiction, and describe in full the reason(s) for the denial, revocation, or suspension. A copy of any order of denial, revocation, or suspension shall be attached to the application. Is this attached? ____________________

3. A statement whether the applicant has been convicted, or is awaiting trial on pending charges, of a "specified criminal activity" as defined in Section II, subsection (22) and, if so, the "specified criminal activity" involved, the date, place and jurisdiction of each must accompany this application. Has this been attached? _______________

SECTION C

Your signature on this application will be taken as an admission that you have read and understand the application form and Section _______ of the (City/County) Sexually Oriented Business ordinance.

Within thirty (30) days, you will either be issued a license for a sexually oriented business employee by the (City/County) Clerk's office or written notice by certified mail of the denial of issuance of a license.

(Signature): _______________________________________________________________

THE STATE OF _____________

(CITY/COUNTY) OF _____________

BEFORE ME, the undersigned authority, on this day personally appeared:

_______________________________________ who being by me duly sworn, deposes and says that he/she has carefully read the foregoing application and that all the facts and statements made are true and correct.

SUBSCRIBED AND SWORN TO BEFORE ME this ___________ day of

____________________, _______.

(month) (year)

_____________________________________________________

NOTARY PUBLIC IN AND FOR THE STATE OF __________

_____________________________________________________

(Print Name)

My Commission Expires:

___________________

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FOR OFFICE USE ONLY

Investigated by Officer ___________________________

Approved _____________ Denied ______________

Director's Approval ____________________ Building Approved _____________________

Building Denied _____________________ Identification Cards Issued ___________________

Tax Approved ____________ Tax Due _____________

License Fees Paid __________________