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For all municipal business limner question:, mdad: clµ 05outh Bend . Crepanmentof Community Imeztment <br />227Wert Jefferson Blvd • Suite 14005 -South Bend, Indiana 46601 • 574.235.5912 • F: 524.235.5021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -4-35 <br />III. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Business Address: <br />Residential Address: <br />IV. PERSONAL DATA <br />A. Applicant's Legal Nam <br />B. Residential Address: <br />City: SLBb1'6L$G State: I zip: N (e(¢l7 <br />C. Residential Telephone Number: <br />D. Residential Fax Number. <br />E. Celephone Number- <br />F. E-Mail Address;- <br />G. Position with business: aW IO'nfesai AP- <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 Ilst all addresses for three (3) years prior to application date: <br />Street Address City State Dates <br />f.L[XY'PA& k if <br />(Attach additional sheets if necessary) <br />