TOWN OF MELBOURNE BEACH, FLORIDA APPLICATION FOR IDENTIFICATION CARD FOR EMPLOYEES AND INDEPENDENT CONTRACTORS EMPLOYED BY PHYSICAL CONTACT ESTABLISHMENTS, ADULT BOOKSTORES, ADULT DANCING FACILITIES AND ADULT MOTION PICTURE THEATERS
Check one:
Initial application
Renewal application
Date
1. Application fee of $15.00 must be submitted with this Application.
2. State the name and business address of the employer for which you requested this identification card.
3. State your name, local address and date of birth.
4. State whether you have been convicted within five years of the date of this application of any felony, or soliciting for prostitution, pandering, prostitution, keeping a house of ill fame, lewd or lascivious behavior or sale or possession of a controlled substance or narcotic.
5. If the answer to question 4 was yes, state the date and place of conviction and the nature of the crime for which you were convicted.
No application shall be complete until the applicant has been fingerprinted in the presence of a Police Officer employed by Melbourne Beach, Florida on a form approved by the Police Department and said fingerprints have been attached hereto; and the applicant has submitted two current color head to shoulders photographs.
I HEREBY SWEAR that the answers to the above are true and correct, that I have read and understand the provisions of Chapter 61 of the Code of Ordinances of the Town of Melbourne Beach, Florida, entitled "Community Standards," that I consent to an investigation of my criminal record, and to the submission of my name, address, date of birth and my fingerprints to the Federal Bureau of Investigation for a fingerprint check, and that I am under a continuing obligation to update the information contained in this application.
SWORN TO AND SUBSCRIBED BEFORE
ME THIS DAY OF
, A.D., 199
NOTARY PUBLIC
MY COMMISSION EXPIRES: