Adult Business License

License Application for - Adult Business

MUNICIPAL CODE SECTION – 4-18.5
South Bend Municipal Code: Section 4-18.5

GENERAL INSTRUCTIONS:
1. Thoroughly review all applicable Municipal Code Sections listed above.
2. Include $5.00 application processing fee made payable to City of South Bend.
3. License fee payable to City of South Bend - $500
4. Add 10% to license fee if renewed after the expiration date.
REQUIRED INFORMATION AND MATERIALS:
1. Must provide a sketch or diagram of the premises.
APPLICATION PROCESS:
1. Review South Bend Municipal Code: Section 4-18.5 thoroughly.
2. Submit Application and pay $5.00 Processing Fee.
3. Inspections by the Fire Department and Building Department as required.
4. License issued upon approval and payment of the $500 license fee.

Application Type
Is this application pertaining to a new business or are you renewing your existing permit?*

New PermitRenew Permit
Business Data
Business Name*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does Mailing address differ from Property Address?*

Yes, different addressNo, Same address
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Business Email Address*
example@example.com
State of Incorporation (if incorporated)
Total Floor Space*
(in square feet)
General Description of Nature of Business*
If business is in operation, date on which owner acquired the Adult Business

MonthDayYear
If business is in operation, date on which Adult Business began operation

MonthDayYear
If business is NOT in operation, what is expected startup date?

MonthDayYear
Personal Data
Owner's Legal Name*

First NameMiddle NameLast Name
Owner's Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner's Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Owner's Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Owner's Email*
example@example.com
Last Four Digits of Owner's Social Security Number*
Copy of Owner's Driver's License or other Government-Issued ID.*

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Owner's Gender*
Owner's Race*
Owner's Date of Birth*

MonthDayYear
Is there an operator different from the owner?*

YesNo
Operator's Legal Name*

First NameLast Name
Operator's Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Operator's Home Number
Please enter a valid phone number.Format: (000) 000-0000.
Operator's Cell Number*
Please enter a valid phone number.Format: (000) 000-0000.
Operator's Email*
example@example.com
Operator's Social Security Number*
Copy of Operator's Driver's License or other Government-Issued ID*

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Operator's Gender*
Operator's Race*
Operator's Date of Birth*

MonthDayYear
Does this business have a Registered Agent?*

YesNo
Registered Agent's Legal Name*

First NameLast Name
Registered Agent's Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Registered Agent's Cell Number*
Please enter a valid phone number.Format: (000) 000-0000.
Registered Agent's Email*
example@example.com
Upload sketch or diagram showing the configuration of the premises

Cancelof
Signature
I, hereby, certify and affirm that all the information I have given in this application is true and accurate to the best of my knowledge. I further certify that I have in no way attempted to mislead the City in this application by omitting facts known to me. I have read and understand the regulations of the Adult Business license found in the City of South Bend Municipal Code, Sections 4-18/5, 12-1, 12-2, 12-3, 12-3.5, and 12-6.
Electronic Signature*

First NameLast Name
Date*

MonthDayYear
Should be Empty:

License Application for - Adult Business

GENERAL INSTRUCTIONS:

REQUIRED INFORMATION AND MATERIALS:

APPLICATION PROCESS:

Application Type

Business Data

Personal Data

Signature