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For all municipal Business Ilcense questions, contact: CM1v, of SoutB Bend • Department of community Investment <br />229 West Jefferson Blvd • Suite 14W S -South Bend, InGlana 46601 • 574135.5912 • F. 514.235.9021 <br />LICENSE APPLICATION FOR -TRANSIENT MERCHANT <br />MUNICIPAL CODE SECTION -4-60 <br />V. PERSONAL DATA (Additional Owner, if applicable) <br />A. Owners Legal Name:. <br />B. Residential Address: <br />C. Residential Telephone Number: <br />D. Celephone Number: <br />E. Position with business: <br />F. Social Security Number: <br />G. Gender: <br />H. Date of birth: <br />VI. INCLUDE $5.00 PROCESSING FEE WITHAPPLICATION <br />VII. INCLUDE NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ALL GROUP EVENT PARTICIPANTS. <br />Vill. INCLUDE A CURRENT CERTIFICATE OF LIABILITY INSURANCE WITH THE CITY OF SOUTH BEND LISTED <br />AS THE CERTIFICATE HOLDER. <br />IX. AFFIRMATION <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 understand that the <br />completed application must be filed no later than thirty days before the planned event is to <br />begin. I have read and understand the regulations of the Transient Merchant license found in <br />the City of South Bend Municipal Cade, Section 4-60. <br />L� 4 3 23 <br />Signature Date <br />