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For all municipal budnee sovoe queroom, coned: [ay MSouth Bend • UgprtmeM of Cemmunlly InveslmeM <br />2r WeNlenenon am • Sulte lmo5 -South Bend, Indiana 46601 • 574.235.5912 • F. 574.235.9021 <br />LICENSE APPLICATION FOR -MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III. OWNERSHIP (Continued <br />3. Co ration (Continued) <br />Business Address: <br />City: State: Zip: <br />Residential Address: <br />IV. PERSONAL DATA T <br />A. Applicant's Legal Name: L eb Ora V\ <br />Du'Hn 13P✓ d ca'ae. =0 <br />C. Residential Telephone Number: 7 f `t — OL6'1 — C;j l z:5 O <br />D. Residential Fax Number: tI4' Z/�= <br />E. Cellphone Number... rJ1 <br />F.E-Mall Address: _T Q i'rDh 00. (@ <br />G. Position with business: UlAinor <br />H. Please list all criminal convictions (if any), excluding trafficviolations: <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 />Street Address City State Dates <br />F25r'�1a Locus+'oad 50t '*ACA .N Iqq-7— prrStom <br />(Attach addition <br />J. Date of <br />K. Gender: <br />L. Social Se ur' N <br />M. Race: <br />3 <br />