APPLICATION FOR ADULT ESTABLISHMENT LICENSE
1. Applicant’s full name: ____________________________
2. Aliases or other name applicant known by/uses: ________________________________________
___________________________________________________________________________________
3. Residence address for last two years: ___________________________________________________
___________________________________________________________________________________
4. Business phone: (____) ___________________ Home phone: (___) ___________________
5. Applicant’s occupation: ________________________________________
6. Applicant’s date of birth: ________________ Driver’s license number: ________________
Social Security Number: __________________
7. Applicant’s place of birth: _____________________
8. Name of Adult Establishment: __________________________________________
9. Address of Adult Establishment: _____________________________________________________
____________________________________________________________________________________
10. Northampton County Parcel Identification Number: ________________________
11. Owner of property: _____________________
Owner’s address: ________________________________________
12. If the persons identified as the fee owner(s) of the tract of land and is/are not also the owner(s) of the establishment, then the lease, purchase contract, purchase option contract, lease option contract or other document(s) evidencing the legally enforceable right of the owners or proposed owners of the adult establishment to have or obtain the use and possession of tract or portion thereof that is to be used for the purpose of the operation of an adult establishment.
13. A current certificate and straight-line drawing prepared within 30 days prior to application by a registered land surveyor depicting the property lines and the structures containing any existing sexually oriented businesses within 1,320 feet of the property to be certified; the property lines of any established religious institution/synagogue, school, library or public park or recreation area within 1,320 feet of the property to be certified. For purposes of this section, a use shall be considered existing or established if it is in existence at the time an application is submitted.
14. Description of adult entertainment to be performed.
___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ _____________________________________________________________________________________
IF ADULT ESTABLISHMENT IS A PARTNERSHIP, CORPORATION
PLEASE PROVIDE THE FOLLOWING:
15. Names and addresses (last two years) of partners/directors, officers or 10% shareholders:
16. I, ____________________________, swear and affirm that I have signed under oath that I have personal knowledge of the information contained in the application and that the information contained therein is true and correct and that the applicant has read the provision of the ordinance regulating adult establishments.
Signature: ____________________________ Date: ________________
NORTH CAROLINA
COUNTY OF _____________________
I, _______________________________, a Notary Public for said County and State, do hereby certify that ________________________ personally appeared before me this the ___________ day of __________, 200 , and acknowledged the due execution of the foregoing instrument.
(Official Seal)
___________________________________
Notary Public
My Commission expires: ______________________
APPLICATION FOR ADULT ESTABLISHMENT ENTERTAINER LICENSE
TOWN OF CONWAY
1. Applicant’s full name: ____________________________________
2. Aliases or other name applicant known as/has used: _____________________________________
___________________________________________________________________________________ ______________________________________________________________________________________
3. Residence address of applicant (last two years): ________________________________________
___________________________________________________________________________________ ____________________________________________________________________________________
4. Home phone number: (___) ____________ Other phone number: (___) ______________
5. Applicant’s date of birth: __________________
6. Applicant’s Social Security No. ___________________ Drivers License No. _______________
7. Applicant’s place of birth: _________________________________
8. Applicant’s stage names or nicknames used in entertaining: _______________________________
___________________________________________________________________________________ ____________________________________________________________________________________
9. List the last five establishments and their addresses where you performed:
___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
10. Name of Adult Establishment where you will work: _________________________
11. Address of Adult Establishment where you will work: ____________________________________
_____________________________________________________________________________________
________________________________ ____________________
Signature of Applicant Date of Application
AUTHORIZATION TO RELEASE INFORMATION
I, ______________________, have not been convicted of, released from confinement of, or diverted from prosecution on:
(a) a felony criminal act within five (5) years immediately preceding the application, or
(b) a misdemeanor criminal act within two (2) years immediately preceding the application, where such felony or misdemeanor criminal act involved sexual offenses, prostitution, promotion of prostitution, sexual abuse of a child, pornography or related offenses as defined in the laws of North Carolina or any oilier comparable violation of the laws of this state or the laws of any other state.
I hereby authorize, request and direct any person, institution or organization, and all governmental agencies and instrumentalities (local, state, federal) to release to the Town Clerk, the Conway Police Department, or any designee, the documents and information required to meet the standards set forth above. Said information can be furnished if the request is made in person or in writing.
Further, I appoint the Town Clerk, the Conway Police Department, or any designee as my agent and attorney-in-fact for the sole purpose of collecting information for processing my application to include fingerprinting. I also direct that the Town Clerk , the Conway Police Department, or designee, be permitted to make copies thereof at his or her discretion. This request may be treated as if I were making the request in person.
I agree to furnish within ten (10) days a criminal history from the clerk of court of any county in which I have resided during the five (5) preceding years.
Date: ________________ Signature: _______________________
I, _________________, do solemnly swear (or affirm) that I am the person who executed the above authorization; I understand its meaning, intention and effect and, the statements therein are true and correct.
A photocopy of this release form will be valid as an original thereof, even the said photocopy does not contain the original writing of my signature.
Date of Birth: _____________________ Social Security Number: _______________________
_______________________________
Signature
Sworn to (or affirmed) and subscribed before me this ___________ day of 200____.
(Official Seal)
___________________________
Notary Public
My Commission expires: ________
(Ord. passed 2-4-2002)