Town of Stallings
P.O. Box 4000
Stallings, NC 28106-4000
The undersigned applicant for an Adult Live Entertainment Privilege License pursuant to Ordinance of the Town of Stallings first being duly sworn deposes and says:
1. Applicant's name is: ______________________________________________________________
2. Applicant's date of birth is: ________________________________________________________
3. Applicant's residence address is: _____________________________________________________
4. A complete statement of the previous business or occupation of the applicant for the two years immediately preceding the date of this application including any adult entertainment experience:
_______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________
5. The address of the premises where the adult establishment business where you will be working is located: _________________________________________________________________________
6. The telephone number of the adult establishment business where you will be working:
(___) ________________________
7. A complete statement of all convictions of the applicant or any person listed in paragraph 3 above for any felony or misdemeanor or violation of a local ordinance: _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________
8. A complete statement of any revocation by any governmental unit of any license to engage in the business or professional adult live entertainment held by the applicant: _____________________
_______________________________________________________________________________ ________________________________________________________________________________
9. The place of applicant's birth: ______________________________________________________
10. The name of the applicant's parents: __________________________________________________
(over)
11. The residence address or address of the applicant for the past five years: _____________________
_________________________________________________________________________________
12. Measurements: Height ___________
Weight ___________
Bust ___________
Waist ___________
Hips ___________
This ______ day of ____________________, 20 _____.
_______________________________________________
Applicant
Sworn to and subscribed before me
this ______ day of _____________________, 20 ____.
_____________________________________________
Notary Public
(Ord. passed 1-4-99)