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For all municipal business Icanse questions, contact: CRy of South send • Department of Ccmmunfty Imrertment <br />227WCRlefencn BNB • Su Me 1400S •Sour Bend, Ialone e6501 • 524.235.5912 • F: 573.2359021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />Ili. 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 />A. Applicant's Legal Name: kyle 05� 41-gWs <br />B. Residential Address: (ew98 .2Aafd/rs <br />City: /AXC os//w State: alr� Zip: <br />C. Residential Telephone Number: Jar 967 — s-nG 9 <br />D. Residential Fax Number: N/,g <br />E. Cellphone Number: /s7W) V7 - 5r:s" <br />F. E-Mail Address: At. jxaa,c A,/L /a% ousel <br />✓ ✓i <br />G. Position with business:l[/1ALL IL <br />H. Please list all criminal convictions (if any), excluding trafRcviolations: <br />Nature of Conviction City State Date <br />AMA/6 <br />(Attach additional sheets if necessary) <br />I. Please list all addresses for three (3) years prior to application date: <br />Street Address City State Dates <br />6A&mC A/1MMd5 % F/jjx�J' <br />(Attach additional sheets if necessary) <br />J. Date of birth: <br />K. Gender: <br />L. Social Sar rarity hh�� hor- <br />M. Race: <br />3 <br />