Town of Stallings
P.O. Box 4000
Stallings, NC 28106-4000
The undersigned applicant for an Adult Establishment Privilege License pursuant to an Ordinance of the Town of Stallings first being duly sworn deposes and says:
1. Applicant's name is: ________________________________________________________________
2. Applicant's residence address is: ______________________________________________________
________________________________________________________________________________
3. If applicant is a partnership, corporation or association:
a. The name of the registered agent: _______________________________________________
b. The address of the registered office: ______________________________________________
________________________________________________________________________________
c. The name and address of all persons having any legal or beneficial interest in the applicant:
_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________
4. The address of the premises where the adult establishment business shall
be located: ______________________________________________________________________
________________________________________________________________________________
5. The telephone number of the adult establishment business: (___) __________________________
6. A complete statement of all convictions of the applicant or any person listed in 3(c) above for any felony or prostitution or any violation of the law relative to prostitution: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
7. A complete statement of any revocation by any governmental unit of any license to operate an adult establishment held by the applicant or any person listed in 3(c) above: _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________
8. A complete statement of any conviction of the applicant or any person listed in 3(c) above for violations of any statute, law, ordinance or regulation of any government concerning the operation of an adult establishment: __________________________________________________________
_______________________________________________________________________________ _______________________________________________________________________________ _________________________________________________________________________________
9. The name and address of any adult establishment or other establishment owned or operated by any person whose name is listed in 3(c) above wherein the business of an adult establishment is carried on other than the business for which this application applies: _______________________________
_______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________
10. A description of any other business to be operated on the same premises or on adjoining premises owned or controlled by applicant and whether the adult establishment business is the principal use of said premises or an accessory use: ________________________________________________
_______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________
This the _______ day of ___________________, 20 ______.
________________________________________________
Applicant
Sworn to and subscribed before me
this ______ day of __________________ 20 ______.
____________________________________________
Notary Public
My commission expires: _______________________
(Ord. passed 1-4-99)