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For all municipal hunnneea license quertlon , mrmot City of South Bend • Department of Community Imrestment <br />227 Wert Jefferson Blvd • Suite 1400 S •South Bend, Ind lam 46601 •574.235.5912 • F: 9123SM21 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name #3: <br />Business Address: <br />Residential Address: <br />City- State: zip <br />IV. PERSONAL DATA <br />A. Applicant's Legal Name: 50idi V_0° VR Z.t¢1L <br />B. Residential Address: OJ`C'k'.4- MRRA.R+J QD <br />City: LSrY.¢VtkC state: \J zip: �A6S241dr <br />C. Residential Telephone Number: Urn. <br />D. Residential Fax Number. rJlor fA <br />E. Cellphone Number: 51-LA 5710 <br />F.E-Mail Address: 44tQARnSF2sF7.:¢2@ G-v-�A�L -(A t'1 <br />G. Position with business: ie%U).Ye2 X2 V%&%%fdne TVLEe Ill <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 />Z "Pal-oraz 2A \_kLZV\\A>c \V 0StNLF la" <br />(Attach additional sheets if necessary) <br />