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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 - 4-3S <br />III. OWNERSHIP <br />A. Type of ownership (check nne): <br />Sole Proprietorship (If sole proprietorship, proceed to 1). <br />Partnership (If partnership, proceed to 2). <br />•r <br />Corporation (If -,corporation, proceed to3). LLC <br />Sole Proprietor <br />Name: <br />Residenti <br />City: _State: /41 Zip: <br />2. Partnership (List at least two (2) partners) <br />Name #1: <br />Residential Address: <br />City: <br />Name #2: <br />Residential Address: <br />Zip: <br />City: State: Zip: <br />3. Corporation In I <br />Legal name of corporation: � e \rAc�I cy-ol2en �-� I �'S LLC_ <br />Date and state of incorporation: & " 1'4 ` 92�, <br />List officers and direc//tors lwho own 15% or more of stock: <br />Name #1: XU _ o Z <br />Title: OItJf L�- <br />Business Address: ' 1 CXII r" <br />City: t �C7U-V\_ ��)QTld State: Zip: "A'C' tq <br />Residential Address: - P,- <br />City:e_f � iS�noo ox 0 state: =1'� - Zip: (P <br />Name #2: <br />Title: <br />Business Address: <br />City:. <br />Residential Address: <br />City: <br />State: Zip: <br />Zip: <br />