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Far all mumclpal business license questions, mina¢ CM of south Bend • Department ofCommunsy Imedrnent <br />227 Wert MHeraon 81W • Suite 14005 -South Band, Indiana 46601 • 514.2355912 • F'. 90.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -4-35 <br />III. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name p3: <br />Title: <br />Business Address: <br />City: State: TIp: <br />Residential Address: <br />City: State: Zip: <br />IV. PERSONAL DATA <br />A. Applicant's Legal Name:No <br />�e���7�, <br />B. Residential Address: // �n" L�IFA y I �idi�is <br />City: ��� 9State: Zip: /( <br />C. Residential Telephone Number: C? SR Sl f% 13T 700\ <br />D. Residential Fax Number: <br />E. Cellphone Number: <br />ll pp 3I Z / O <br />F. E-Mail Address: <br />G. Position with business: OVJ�`QA <br />H. Please list all criminal convictions (if any), excluding trefficviolations: <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 />S'Gt lrv��f <br />(Attach additional sheets if necessary) <br />K. Gender: <br />