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For all municipal business license questions wreact: City of South Bend • Department of Community Invesbnem <br />227Wertleffemon Blvd -Suite 14WS South Bend, Indiana 06601 v 570335.S912• F 574235.9D21 <br />LICENSE APPLICATION FOR -MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III. 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 Na—_. A4\.If t• Qir:C <br />B. Residential Address: <br />City: C&� State: Zip: ylaLly <br />C. Residential Telephone Number: <br />D. Residential Fax Number: <br />E. Cellphone Number: <br />F. E-Mail Address: <br />G. Position with business: x90 b,;o.4 f <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 />raB N %Ll V b�%DE)atkn l <br />3 <br />