City of Cape Girardeau, Missouri

401 INDEPENDENCE
P.O. BOX 617
CAPE GIRARDEAU, MO 63702
Phone: 573-334-1332 Fax: 573-335-7946

Application for Adult Entertainment
Business License

City of Cape Girardeau Seal
Name of Business__________________________________________________________
Address of Business_________________________________________________________
Phone Number ________________________
Description of type of business to be performed on the licensed premises __________________
_________________________________________________________________________
Owner of the premises where the business will be located _____________________________

I, the undersigned, hereby apply to the City of Cape Girardeau, State of Missouri, for an Adult Entertainment Business License on the above described premises. I understand and agree that if I fail to supply all the information requested on the application or if any information given is untrue, application may be denied or license, if granted, may be revoked or suspended.

ALL QUESTIONS ON THIS APPLICATION MUST BE ANSWERED COMPLETELY BEFORE THE APPLICATION WILL BE CONSIDERED. ANSWERS MUST BE TYPED OR LEGIBLY PRINTED.

1. To be completed regarding the Applicant
Name __________________________________________________________________
Home Address ____________________________________________________________
Date of Birth___________________  Place of  Birth _______________________________
Social Security #_______________________ Phone Number _______________________
Occupation of Owner _______________________________________________________
2. To be completed by Corporations only (Please include a current certificate of registration issued by the Missouri Secretary of State)
State the exact corporate name of applicant _______________________________________
State the date and place of incorporation _________________________________________
State the address of the principal office of the corporation ____________________________
_______________________________________________________________________
Complete the following on all officers of the corporation:
Full Name Address Social Security No. Date of Birth
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Complete the following on all stockholders who own 10% or greater interest in the corporation:
Full Name Address Social Security No. Date of Birth

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Complete the following on all directors of the corporation:
Full Name Address Social Security No. Date of Birth

__________________________________________________________________________
__________________________________________________________________________
3. To be completed by Partnerships only
State the name of the partnership ______________________________________________
Date partnership was formed _________________________________
Complete the following on all partners:
Full Name Address Social Security No. Date of Birth

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

4. For Partners or Sole Proprietors
STATE OF MISSOURI

COUNTY OF CAPE GIRARDEAU

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__________________________________, of lawful age being first duly sworn upon oaths, depose and say that (he, she) have read this application and the instructions with reference thereto and that (he, she, they) fully understand the same; that (he, she) know the contents and the statements contained therein and that the same are true. Applicant has personal knowledge of the information contained the application and has read the provisions of Article XV of Chapter 15 of the Code of Ordinances of the City of Cape Girardeau, Missouri

________________________________________
________________________________________
________________________________________

Subscribed and sworn before me this __________ day of ___________, ___________.

________________________________________
________________________________________
Notary Public

My Commissions Expire:
_______________________