Adult Entertainment License Application

2. City Clerk's Office
   (712) 328-4616

   (712) 328-4616

4. Business Information

6. Business name

8. Business address

9. Phone

11. Owner's name

13. Owner's address

14. Phone

16. Place of birth

17. Date of birth

19. Type of business
    -- Select One --Sole proprietorshipPartnershipCorporation

21. Please attach a list of partners and/or corporation officers, state / date of incorporation.

    Please attach a list of partners and/or corporation officers, state / date of incorporation.

23. Describe the business to be conducted at this location

25. Legal description

27. What type of zoning is at this location?

29. Attach a notarized statement as required by the city's Municipal Code - Section 3.15.070(c)7. Attach a copy of the lease or warranty deed.

31. Manager Information

33. Manager's name

34. Phone

36. Manager's address

38. Place of birth

39. Date of birth

41. Attach proof the owner and/or manager is at least 18 years of age.

45. Applicant signature

46. Date

48. Please return payment of $250 by the renewal date of June 30th to:<br>City Clerk <br>209 Pearl St.<br>Council Bluffs, IA 51503

    Please return payment of $250 by the renewal date of June 30th to:
    City Clerk
    209 Pearl St.
    Council Bluffs, IA 51503

Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit Submit and Print

* indicates a required field