_ Application for ‘Niagara UM Region Adult Entertainment Niagara Region 905-980-6000 ext. 6380 Business Licensing niageraregion.calbusiness 5859 Peer Steet, Second Floor lee complete and return this form in person agora Falls, Oriana, L2G 14 m ete and return his form in Olnitat Appicaton (O Renewal (© Replacement Applicant’ full name: Applicant's stage name: Dato of bith mms *County of birt “Proase noe bom cusie Canad, roa af teen, landed immigrant satis endo vas work permit requ, Heiaht: Weight Hale colour Eye colour Address iy: Postal code: Phone number: Cell phone number: List al adult entertainment clubs you Intend to work at: All applicants must answer the following questions: Have you ever been convicted of an offence under the Criminal Code of Canada (for which you have not been ‘granted a pardon)? If, lit offences and approximate date of conviction: Have you ever been convicted of an offence under the Controlled Drugs and Substance Act (for which you have not boen granted a pardon)? Iso, it offences and approximate date of conviction: ‘Aepleatn fr Adi Eneanment Leone | June 2078Atleast two ofthe following places of identification must be provided, as well as Government proof ‘of Social Insurance: Passport, Chizenship Card, Birth Cerifcat, ith Registration, Baptismal Certifcate, Driver's Licence, Immigration Documents, Status Card, Nexus, LCBO Identification Card and Provincial Identification card ‘Atleast one of the above pleces of Identification must have a photograph. The applicant understand that ‘a copy of the photograph and a copy ofthe Application Registration wil be retained by the Licencing office {or a peried of two years. Al Appicants must provide government proof of thelr Social Insurance Number along with the required identification. Declaration: |, the applicant, understand that making a false stalement in this application could resuln a refusal to fssue a Fence, or n suspension of revocation of licence ata later date, | neroby authorize release fo the Niagara Region any and all particulars of my eminal recor. In consideration ofthe release ofthe information by the Niagara Region. | hereby release and forever discharge Nagara Region and all ofits members for damages or fr loss or injury arsing out ofthe release of Information Felaing to my criminal record and my driving record which may hereafter be sustained by me. | corti that the above information is tre to the best of my knowledge, information and belle. | understand that feo of $26.00 wil apply | am refused a licence because of my criminal history ‘Signature: Dato fmmtiy For office use only Completed by (fle no: cM pn. Aenean for Adu Enleraenat Licence | une 28 2ADULT ENTERTAINERS + Two pieces of valid Government issued identification. One form of identification must contain your photo * Police Criminal Record Check and Judi Check (not older than 30 days). + Offer of employment. “Proof of Eligibility to Work in Canada** Ifa licence applicant is born outside of Canada, proof of citizenship, landed immigrant status and/or a valid work permit Is required at the time of application. All applicants, born in Canada or outside Canada, must provide proof of a valid Social Insurance Number at the time of licence application. (No record of the actual Social Insurance Number ls maintained by the Licensing Office.)