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For all municipal business license questions, contact; City of South Bend -Department of Community Investment <br />227 West Jefferson Blvd a Suite 1400 5 -South Bend, Indiana 4660I ® 574,235.5912 e F: 574.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -4-35 <br />IV. PERSONAL DATA (Continued) <br />N. Photographs: <br />Attach below (3) Passport photos, l"xi", taken within 6 months of the date of this application. <br />903 E. Jefferson E3Ivd. South Bend, IN 4uti1 i r&u 1-7 - I �Izu 4 r <br />(Attach additional sheets if necessary) <br />V. INCLUDE WITH APPLICATION: <br />Three (3) passport photos taken within 6 months of application. <br />VI. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION <br />VII. AFFIRMATION <br />1, hereby, certify and affirm that all of the information I have given in this application is true and <br />accurate to the best of my knowledge. I further certify that I have in no way attempted to <br />mislead the City in this application by omitting facts Known to me. I agree to cooperate with any <br />review conducted pursuant to the licensing procedures, including permission to enter and <br />inspect the place of business and facilities in conjunction with such review. I have read and <br />understand the regulations of the Massage Establishment and/or Therapist license found in the <br />City of South Bend Municipal Code, Section 4-35. <br />Signature <br />4 <br />Date <br />