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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 46601 e 574.235,5912 • F: 574,235,9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />IV. PERSONAL DATA (Continued) <br />:port <br />ontl <br />O. Please list all previous employment for three (3) years prior to the date,of this application: <br />Company Address City, State, ZIP <br />CU,L <br />e qol L�-' COWL& /�L)e' Sdirl Ev, ad <br />(Attach additional sheet 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 />Dates <br />I, 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 />U'�' %1& <br />Signature . <br />4 <br />MAR 15 2018 <br />Date <br />