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For all municipal business license questions, contact: City of South Bend • Department of Community Investment <br />227 West Jefferson Blvd • Suite 1400 S -South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name #3: <br />Title: <br />Business Address: <br />City: <br />Residential Address: <br />City: <br />IV. PERSONAL DATA <br />State: <br />State: <br />Zip: <br />Zip: <br />A. Applicant's Legal Name: V haf I-E(iZ&de :IDMu31)11 <br />B. Residential Address: `{64 g� Ud7 SiDltt Ayt <br />City: South btnd State: :U) Zip: llioblq <br />C. Residential Telephone Number: 21W)M-*�3yq-13kN <br />D. Residential Fax Number: <br />E. Cellphone Number:(5� 3>a i —3loIL <br />F. E-Mail Address: <br />G. Position with bt <br />H. Please list all criminal convictions (if any), excluding traffic violations: <br />Nature of Conviction <br />City State Date <br />(Attach additional sheets if necessary) <br />1. Please list all addresses for three (3) years prior to application date: <br />Street Address City State <br />safq as ahwt. <br />(Attach additi—'-",.,....:F ---------t <br />J. Date of birtl <br />K. Gender:_E <br />L. Social Secm <br />M. Race: 14h <br />Dates <br />