Permit Application for Adult-Oriented Establishments,
Employees, Entertainers or Escorts
Loudon County, Tennessee

Date of Application:__________________

(1) Applicant Name ( including all Alias's):____________________________
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(2) All applicant's must supply written proof of age that the applicant is eighteen (18) years of age.
Please attach a copy of:

a) Driver's License
b) Birth Certificate

(3) Height:____ Weight:_____ Color of Eyes:_______ Color of Hair:___________

4) The adult-oriented establishment or similar business permit history of the applicant; whether such
person, in previously operating in this or any other city or state under permit, has had such permit
revoked or suspended, the reason therefore, and the business activity
or occupation subject to such action of suspension or revocation;
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5) List any conviction for or plea of nolo contendere to a specified criminal act as defined in
TCA 7-51-1102(24): (Listed below):
"Specified criminal acts" means the following criminal offenses as defined by Tennessee Code
Annotated:  (a) Aggravated rape; (b) Rape; (c) Rape of a child; (d) Aggravated sexual battery;
(e) Sexual battery by an authority figure; (f) Sexual battery; (g) Statutory rape; (h) Public indecency;
(i) Prostitution; (j) Promoting prostitution; (k) Distribution of obscene materials; (l) Sale, loan or
exhibition to a minor of material harmful to minors; (m) The display for sale or rental of material
harmful to minors; (n) Sexual exploitation of a minor; (o) Aggravated sexual exploitation of a minor;
and (p) Especially aggravated sexual exploitation of a minor
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6) Attach two (2) portrait photographs at least two inches by two inches (2" x 2") of the applicant.

7) I have read and am familiar with the provisions of this part and am in compliance with them. I certify under oath that this application contains true information to the best of my knowledge and belief. I am aware of my continuing obligation to amend or supplement this application promptly if a change in circumstances affects the responses provided in this application, either before or after a licenses has been issued. I certify that I am knowledgeable of the laws pertaining to the operation of an adult oriented business.

Signature:________________________________ Date:_____________________

(8)A permit fee of one hundred dollars ($100) shall be submitted with the application for a permit.

(9) Failure or refusal of the applicant to give any information relevant to the investigation of the application or the applicant's refusal or failure to appear at any reasonable time and place for examination under oath regarding the application or the applicant's refusal to submit to or cooperate with any investigation required by this part constitutes an admission by the applicant that the applicant is ineligible for such license and shall be grounds for denial thereof by the board.

No adult-oriented establishment shall open to do business before eight o'clock a.m. (8:00 a.m.), Monday through Saturday; and no such establishment shall remain open after 12:00 a.m. (Midnight), Monday through Saturday. No adult-oriented establishment shall be open for business on any Sunday or a legal holiday as designated in TCA 15-1-101.

The opening and closing time limitations placed on adult-oriented establishments in Loudon County shall not apply to an establishment or the portion thereof which offers only live, stage adult entertainment in a theater, adult cabaret, or dinner show type setting.