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For all municipal business license question; correct: City or south Bend • Department a Community Investment <br />222 WaUeRereon Blvd' Suite 1400S 'South Bend, IMlana 46601 • 594.M.5912 • F: 57C235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />Ill. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name #3: <br />Title: <br />Business Address: <br />City: State: Zip: <br />Residential Address: <br />City: State: Zip: <br />IV. PERSONAL DATA � � / <br />n,. A. Applicant's Legylgame: dIL��Ef Lfl <br />B. Residential Address: 16 g tk-� catewtith ciL . _ <br />City: lctk.C,�W�te: 4V Zip: <br />C. Residential Telephone Number: <br />D. Residential Fax Number: <br />E. Celephone Number: IQ -32Ci/y, Lo <br />F. E-Mail Address: J3&c a4a/'o d fill- cl+m-Kl.ri . el m <br />G. Position with business: <br />H. Please list all criminal convictions (if any), excluding trafhcviolations: <br />Nature of Conviction City State Date <br />(Attach additional sheets if necessary) <br />I. Please list all addresses for three (3) years prior to application date <br />StreetQ`ddres5 City State Dates <br />/4, d'/, l 74f i4 sae. A)?CWdWXA 201B AtV <br />(Attach additio <br />J. Date of b' <br />K. Gender: <br />L. Social <br />M. Race: <br />3 <br />