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For all municipal budrem license questions, contact City of south send • Department of Community Iroertment <br />222 West Jefferson Blyd • suite 140e S -South Bend, Indiana 46601 •574.235.5912 • F: 570.235.9@3 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III.OWNERSHIP <br />A. Type of ownership (check one): <br />/ Sole Proprietorship (if sole proprietorship, proceed to 1). <br />Partnership (If partnership, proceed to 2). <br />Corporation (it corporation, proceed to 3). <br />1. Sole Proprietor� ,�.. �//�� � ' <br />Name: s04—e A�9('l.lYi! !IY— <br />Residential Address: '`� lb�,Q Ls) C DA C- <br />City A42 c 4.2 OOA, State: ;A! Zip: <br />2. Partnership (List at leasttm (2) partners) <br />Name #1: <br />Residential Address: <br />City: State: Zip: <br />Name #2: <br />Residential Address: <br />City: State: Zip: <br />3. Corporation <br />Legal name of corporation: <br />Date and state of incorporation: <br />List officers and directors who own 15%or more of stock: <br />Name #1: <br />Title: <br />Business Address: <br />City: State: Zip: <br />Residential Address: <br />City: State:. Zip: <br />Name #2: <br />Title: <br />Business Address: <br />City: State: Zip: <br />Residential Address: <br />City: State: Zip: <br />2 <br />