APPLICATION FOR A (CITY/COUNTY)
SEXUALLY ORIENTED BUSINESS LICENSE
TYPE OF SEXUALLY ORIENTED
BUSINESS LICENSE APPLIED FOR:
ADULT ARCADE ________
ADULT BOOKSTORE ________
ADULT CABARET ________
ADULT MOTEL ________
ADULT MOTION PICTURE THEATER ________
ADULT THEATER ________
ADULT VIDEO STORE ________
ESCORT AGENCY ________
NUDE MODEL STUDIO ________
SEXUAL ENCOUNTER CENTER ________
*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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SECTION A
1. Business Trade Name _____________________________________________________
2. Address of Business ______________________________________________________
3. City/State _________________________Zip __________ Phone __________________
4. Provide a general description of the services to be provided ________________________
_____________________________________________________________________
_____________________________________________________________________
5. If the establishment is in operation, give the date on which the owner(s) acquired the establishment for which the business license is sought, and the date on which the establishment began operations as a sexually oriented business at the location for which the business license is sought.
_____________________________________________________________________
_____________________________________________________________________
6. If the establishment is not in operation, the expected startup date (which shall be expressed in number of days from the date of issuance of the business license). If the expected startup date is to be more than ten (10) days following the date of issuance of the business license, than a detailed explanation of the construction, repair or remodeling work or other cause of the expected delay and a statement of the owner's time schedule and plan for accomplishing the same.
_____________________________________________________________________
7. Person Applying (Applicant) ________________________________________________
8. Applicant's Home Address ________________________________Zip Code__________
Applicant's Home Telephone _________________ Business Phone ________________
9. Applicant's Driver's License # _____________________________ State ____________
10. Applicant's Social Security # _______________________________________________
11. Applicant's Federal Tax Identification # _______________________________________
12. Race ____________ Sex ___________ Date of Birth ____________________________
13. Applicant's Spouse _______________________________________________________
Race ____________ Gender ___________ Date of Birth _________________________
14. Applicant's Relationship to the Business ______________________________________
15. Please identify, by name, the owner of the business listed on line 1:
______________________________________________________________________
16. The owner of the business listed on line 1 is (check one):
________ an individual (e.g., a sole proprietorship)
________ two or more individuals
________ a partnership
________ a corporation
________ other (please specify)
If the owner of the business is an individual, complete Section B, skip Sections C and D, and continue answering at Section E.
If the business is owned by two or more individuals, complete Section C, skip Sections B and D, and continue answering Section E.
If the owner of the business is a partnership, skip Section B, and C, and complete Section D, and continue answering section E.
If the owner of the business is a corporation, skip Sections B and C, complete Section D, and continue answering at Section E.
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SECTION B - TO BE COMPLETED IF OWNER IS AN INDIVIDUAL
17. If the owner of the business is an individual, other than yourself, you (applicant) must submit with this application a signed and notarized statement from the owner of the business declaring that he/she owns the business and that you are his/her designated agent for the purposes of applying for a sexually oriented business license.
18. Owner's Name ____________________________________________________________
19. Owner's Race __________ Sex __________ Date of Birth _________________________
20. Owner's Home Address _____________________________________________________
21. Owner's Home Phone ______________________________________________________
Owner's Business Phone ____________________________________________________
22. Owner's Spouse __________________________________________________________
23. Spouse's Race ____ Gender ____ Date of Birth _________ Driver's License # ________
Spouse's Home Phone _________________ Spouse's Business Phone _______________
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SECTION C - TO BE COMPLETED IF TWO OR MORE INDIVIDUALS CO-OWN THE BUSINESS.
24. If the business is co-owned by two or more individuals, you (applicant) must submit with this application a signed and notarized statement from each of the co-owners other than yourself declaring that each co-owns the business and that you are each co-owner's designated agent for the purposes of applying for a sexually oriented business license.
25. For each co-owner, provide the following information (use addition sheets, if necessary):
(A) Co-owner's Name __________________________________________________________
Co-owner's Race ____ Sex ____ Date of Birth __________ Driver's License # _________
Co-owner's Home Address ___________________________________________________
City ___________________________State __________ Zip ________________________
Co-owner's Spouse _________________________________________________________
Spouse's Race ______ Sex ____ Date of Birth __________ Driver's License # _________
Home Phone ________________________ Business Phone _________________________
(B) Co-owner's Name __________________________________________________________
Co-owner's Race ____ Sex ____ Date of Birth __________ Driver's License # _________
Co-owner's Home Address ___________________________________________________
City ___________________________State __________ Zip ________________________
Co-owner's Spouse _________________________________________________________
Spouse's Race ______ Sex ____ Date of Birth __________ Driver's License # _________
Home Phone ________________________ Business Phone _________________________
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SECTION D - TO BE COMPLETED IF OWNER IS A PARTNERSHIP OR CORPORATION
26. (a) If the owner of the business is a partnership, you (application) must submit with this application a signed and notarized statement from on of the partners declaring that he/she is a partner of a partnership that owns the business that he/she is authorized by the partnership to designate an agent for the purposes of applying for a sexually oriented business license and that you (applicant) are the agent designated.
(b) If the owner of the business is a limited partnership, you (applicant) must submit with this application a certified copy of the Certificate of Limited Partnership on file with the Secretary of State in (City, State).
27. (a) If the owner is a corporation, you (applicant) must submit with this application a signed and notarized statement from an officer of the corporation declaring that he or she has authority to designate an agent for the purposes of applying for a sexually oriented business license and that you (applicant) are the agent designated.
(b) If the owner is a (State) corporation, you (applicant) must submit with this application a certified copy of the Articles of Incorporation (Charter) on file with the Secretary of State in (City, State).
(c) If the owner is an out-of-state corporation, you (applicant) must submit with this application a certified copy of the Certificate of Authority on file with the Secretary of State in (City, State).
28. Corporation or Partnership Name _____________________________________________
29. Mailing Address _____________________________ Zip _______ Phone _____________
30. Partners or Corporate Officers: (Use additional sheets, if necessary)
(A) Name__________________________________________________________________
Home Address __________________________________________ Zip _____________
Driver's License # __________________ Date of Birth ___________ Race ____ Sex ____
Relationship to Business ____________________________________________________
(B) Name__________________________________________________________________
Home Address __________________________________________ Zip _____________
Driver's License # __________________ Date of Birth ___________ Race ____ Sex ____
Relationship to Business ____________________________________________________
(C) Name__________________________________________________________________
Home Address __________________________________________ Zip _____________
Driver's License # __________________ Date of Birth ___________ Race ____ Sex ____
Relationship to Business ____________________________________________________
(D) Name__________________________________________________________________
Home Address __________________________________________ Zip _____________
Driver's License # __________________ Date of Birth ___________ Race ____ Sex ____
Relationship to Business ____________________________________________________
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SECTION E
31. Is there an Assumed Name Certificate on file with the County Clerk's Office for the business listed on line 1 of this application? __________ If so, you must submit with this application a certified copy of the Assumed Name Certificate.
32. ALL CLERKS AND EMPLOYEES: You (applicant) must provide the following information with regard to any person who is, or whom you know will be employed by the business at the physical address of the sexually oriented business located in (City/County) (use additional sheets, if necessary).
Please be advised that under Section _____ of the (City/County) Sexually Oriented Business Order:
"A license issued pursuant to subsection (A) of this section, if granted, shall
state on its face the name of the person to whom it is granted, the expiration
date, and the address of the sexually oriented business. The employee shall
keep the license on his or her person at all times while engaged in employment
or performing services on the sexually oriented business premises so that said
license may be available for inspection upon lawful request."
(A) Name ________________________________________________________________
Home Address ____________________________________ Zip ____________________
Home Phone _______________ Date of Birth _____________ Race ______ Sex _______
(B) Name ___________________________________________________________________
Home Address ____________________________________ Zip ____________________
Home Phone _______________ Date of Birth _____________ Race ______ Sex _______
(C) Name ___________________________________________________________________
Home Address ____________________________________ Zip ____________________
Home Phone _______________ Date of Birth _____________ Race ______ Sex _______
(D) Name ___________________________________________________________________
Home Address ____________________________________ Zip ____________________
Home Phone _______________ Date of Birth _____________ Race ______ Sex _______
33. The Health Department and the Sheriff's Department require that you provide a name and telephone number of the person whom they should contact for their inspections.
Name ________________________________________________________________________
Home Phone _______________________ Business Phone ______________________________
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34. Have you or any other person listed on this application ever been CONVICTED of any crime listed in Section _______ of the (City/County) Sexually Oriented Business Ordinance? ____________
A. Name ____________________________________________________________________
Date of Conviction ____________________ Where _______________________________
Offense __________________________________________________________________
Date of Conviction ____________________ Where _______________________________
Offense __________________________________________________________________
Date of Conviction ____________________ Where _______________________________
Offense __________________________________________________________________
B. Name ____________________________________________________________________
Date of Conviction ____________________ Where _______________________________
Offense __________________________________________________________________
Date of Conviction ____________________ Where _______________________________
Offense __________________________________________________________________
Date of Conviction ____________________ Where _______________________________
Offense __________________________________________________________________
C. Name ____________________________________________________________________
Date of Conviction ____________________ Where _______________________________
Offense __________________________________________________________________
Date of Conviction ____________________ Where _______________________________
Offense __________________________________________________________________
Date of Conviction ____________________ Where _______________________________
Offense __________________________________________________________________
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35. Owner of Building in which business operates ___________________________________
36. Owner of Property on which business operates ___________________________________
You (applicant) must submit with this application, a certified copy of the Deed showing ownership of the property.
37. Do you lease or sublease the building in which the business operates? ________________
38. Name of Leassor ________________________________________________________
39. Address of Leassor ______________________________________________________
40. Is any person listed on this application overdue in his or her payment to (City/County) for taxes, fees, fines, or penalties assessed in relation to a sexually oriented business? _________
41. Has any person listed on this application been denied or had revoked or suspended any similar Sexually Oriented Business license within the preceding 12 months? _______________ If yes, give the name, address, type of license and date when license was revoked.
42. (A) Name ________________________________________________________________
Address ______________________________________________________________
Date of Denial ______________________ Date of Revocation ___________________
43. Does the applicant or a person residing with the applicant hold any other licenses under this ordinance or other similar sexually oriented business ordinance from another city or county and if so, the names and locations of such other licensed businesses. ______________________
__________________________________________________________________________
__________________________________________________________________________
44. Under Section _______ of the (City/County) Sexually Oriented Business Ordinance, attach a sketch or diagram showing the configuration of the premises with this application. Has this sketch or diagram been attached? _______________
45. Please be aware that not less than fourteen (14) days after the filing of this application, the posting requirements under Section ___ of the (City/County) Sexually Oriented Business Ordinance must be complied with.
46. Please be aware that publication notice is required under Section _____. You have fourteen (14) days from the date of the filing of the application to comply. The (City/County) Clerk's office will telephone you to make verification of this requirement. The contact person listed in item number 28 will be used.
IMPORTANT: READ BEFORE SIGNING
Your signature on this application will constitute an admission that you are now or will be, when and if a license is issued, the owner of the business listed on line 1, a partner whose partnership owns or will own the business listed on line 1, or a corporate officer of a corporation which owns or will own the business on line 1. The only circumstance in which your signature will not be taken as such an admission is if you have submitted, along with your application, a signed and notarized statement of the type described in items number 12, 19, 21(a), or 22(a) of this application.
You are specifically reminded that Section _____ of the (City/County) Sexually Oriented Business Ordinance states:
"If a person who wishes to own or operate a sexually oriented business
is an individual, he must sign the application for a business license as
applicant. If a person who wishes to operate a sexually oriented business
is other than an individual, each individual who has a ten (10%) percent
or greater interest in the business must sign the application for a business
license as applicant. If a corporation is listed as owner of a sexually
oriented business or as the entity that wishes to operate such a business,
each individual having a ten (10%) percent or greater interest in the cor-
poration must sign the application for a business license as applicant."
Your signature on this application will be taken as an admission that you have read and understood the application form and the (City/County) Sexually Oriented Business Ordinance.
Within thirty (30) days, you will either be issued a license for a sexually oriented business by the (City/County) Clerk's office or written notice by certified mail of the denial of issuance of a license.
(Signature): ____________________________________________________________________________
(circle one) OWNER, PARTNER, CORPORATE OFFICER, OR DESIGNATED AGENT
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:
___________________
(Signature): ____________________________________________________________________________
(circle one) OWNER, PARTNER, CORPORATE OFFICER, OR DESIGNATED AGENT
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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(Signature): ____________________________________________________________________________
(circle one) OWNER, PARTNER, CORPORATE OFFICER, OR DESIGNATED AGENT
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 __________________