Neighborhoods and Housing Services Department
Regulated Industries Division
635 Woodland Ave., Suite 2101
Kansas City, MO 64106
(816) 513-4560
Adult Entertainment Permit Application
Applications are accepted from 8:00 a.m. to 4:30 p.m. Monday – Friday at the Regulated Industries Division
office. All applicants must be authorized to work in the United States. In order to submit an application for an
entertainer’s permit, applicants must submit a $51 non-refundable application fee. In order to submit an application for
a manager’s permit, applicants must submit a $54 non-refundable application fee. Only cash, Discover, Master Card or
Visa are accepted (checks are not accepted). Along with the application, an applicant must also submit a valid State
Issued Driver's License or ID and one of the following: (Social Security Card without employment restriction; U.S.
Passport or Passport Card; Permanent Resident Card [i.e., Green Card]; Foreign Passport with I-551 stamp MRIV;
Employment Authorization Card; Form I-20 accompanied by Form I-94 or Form I-94A; Form DS-2019 accompanied by
Form I-94 or Form I-94A; or Form I-94; Form I-94A Arrival/Departure Record; Birth certificate issued by the U.S.
Department of State; U.S. Citizen Identification Card Form I-197; or Identification Card for Use of Resident Citizen in the
U.S. Form I-179). Fake, false or altered identification cards will be confiscated.
If an applicant fails to submit their correct social security number, they will be required to pay an additional $52
dollars to complete a second background check and a second temporary permit will not be issued. There are restrictions
listed under section 12-57 of the Code of Ordinances of the City of Kansas City, Missouri, that may prohibit you from
receiving an adult entertainment permit. Please read below to determine your eligibility:
 The applicant has not made any false, misleading or fraudulent statement in the application for a license, or in the
providing of documentation of age, as part of the original permit application or application for renewal thereof.
 The applicant has attained the age of 18 years.
 The applicant has not been convicted of a felony or released from confinement for conviction of a felony,
whichever event is later, within five years immediately preceding the application, where such felony involved
sexual offenses, prostitution, sexual abuse of a child or pornography and related offenses, as defined in the state's
criminal code, RSMo chs. 556--600, or similar statutes, or controlled substance or illegal drugs or narcotics
offenses, as described in the state comprehensive drug control act, or similar statutes.
 The applicant has not been convicted of a misdemeanor or released from confinement for conviction of a
misdemeanor, whichever event is later, within two years immediately preceding the application, where such
misdemeanor involved sexual offenses, prostitution, sexual abuse of a child or pornography and related offenses,
as defined in the state's criminal code, RSMo chs. 556--600, or similar statutes, or controlled substance or illegal
drugs or narcotics offenses, as described in the state comprehensive drug control act, or similar statutes.
 The applicant has not been convicted of a municipal ordinance violation or released from confinement for
conviction of a municipal ordinance violation, whichever event is later, within two years immediately preceding
the application, where such municipal ordinance violation involved indecent exposure, prostitution, or sale of
controlled substances or illegal drugs or narcotics.
 The applicant has not had a license or permit issued under the provisions of this article revoked within five years
immediately preceding the application.
I hereby make application for the following:
 Adult Entertainer
 Adult Entertainment (Bookstore) Manager
 Adult Live Entertainment Manager
1. Name __________________________________________________________________________________________
First
Middle
Last
Maiden name/Other
2. Birth date ________________________ Social Security Number _______________ -___________ -______________
3. Address ____________________________________________________________________________________
Number
Street
City/State
Zip Code
4. Home Phone ____________________________________________ Mobile Phone __________________________
5. Gender ____ Age ______ Height ______ Weight _______ Hair Color _________ Eye Color __________
6. Entertainer Stage Name_____________________________________________________________________
7. Driver's License or State ID Number ____________________________________State Where Issued ____________
8. List the name of each Adult Entertainment Business at which you intend to work in Kansas City, Missouri.
1. _______________________________________________________ 2. _____________________________________________________
9. Have you had a license or permit issued under the provisions of this article revoked within five years immediately
preceding the application, or, have you ever been convicted of a felony or released from confinement for conviction of
any felony within the last five years, or, have you been convicted of any misdemeanor or released from confinement for
conviction of a misdemeanor, whichever event is later, within two years immediately preceding the application, where
such felony or misdemeanor involved sexual offenses, prostitution, sexual abuse of a child, pornography or related abuses,
or controlled substances, illegal drugs or narcotics offenses; or have been convicted of, or released from confinement for
conviction of, any municipal ordinance violation, within the last two years, where such violation involved indecent
exposure, prostitution or sale of controlled substances, illegal drugs or narcotics?
 Yes  No
If yes, provide the following information:
Date
Offense/Conviction Charge
Where (City and State)
___________________ ______________________________ ______________________________________________
___________________ ______________________________ ______________________________________________
I hereby authorize law enforcement, probation and parole agencies to release all information pertaining to any criminal
record and Social Security number trace. I understand that furnishing false or incomplete information on this application
may be grounds for denial of the permit I am seeking. I also understand that there is no refund of the fee that accompanies
this application if, for any reason, it is denied.
You may request to have your Adult Entertainer or Manager Permit mailed to you at the address you indicated above. If
you choose to have your permit mailed to you and your permit is returned to us, you will be required to return to
Regulated Industries to pick up your permit. If you choose to have your permit mailed to you and your permit is lost in
the mail, you will be required return to Regulated Industries and pay a $10 replacement fee before your permit will be
issued. Please choose one of the following options:
 Please mail my permit to me for an additional 50 cents
 I will return to Regulated Industries to pick up my permit (required if all forms of ID not presented w/ application)
I, ________________________________, being of lawful age and duly sworn upon my oath do swear that the answers
Print Name
and information in this application are true and complete to the best of my knowledge and belief.
Applicant's Signature _________________________________________________ Date _____________________
Office Use Only
Seal
State of Missouri
County of ____________________________
Subscribed and sworn before this _______ day of ______________________________, ______________.
_____________________________
My Commission Expires
_____________________________________________________
Notary Public
Processed by ________________________ Date ____ / ____ / _____ Certificate # ______________________________
Month Day Year
--------------------------------------------------------------------------------------------------------------------------------------Did the criminal background investigation prohibit the applicant from receiving a permit?
 Yes
 No
The Permit was  Approved  Denied __________________________________ Date ____ / ____ / _____
Investigator
11-1-2016