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For all munidpal business Incense quarters, contaseeny of South Bend • Department of community InWebeem <br />237W6t10eerson BW • 5uIW 140Q5 •South BeM. Indiana 46601 • 574.2356912 • 2:514.135.9012 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III. OWNERSHIP <br />A. Type ofownershl checkone): <br />Sole Pmprietorshlp (If sole proprietorship, proceed tol). <br />Partnership (If partnership, proceed to 2). <br />Corporation (If corporation, proceed to3). <br />1. Sole Proprietor D60O_r�CCA K Iar-FD N <br />AYys <br />Name: �L �OVJE:,Vj4(-�'q(1AV5c <br />2 Wa. <br />Residential Address: Rt5a C u J ' DR <br />cRy:6rj I-jLeVA6 State: T N let Liu LA I <br />2. Pa ership (List at least two (2) partners) <br />Name #1: <br />Name#2: <br />Residential Address: <br />3. C oration <br />Legal name of corporation:_ <br />Date and state of Incorporation: <br />List officers and directors who own 15%or more of stock: <br />Business Address: <br />City: State: Zip: <br />Residential Address: <br />