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For A muMapal Business liceme qo rrns,wdea: Gq ofSauth Bend• Depanmem d rummunity meesiment <br />W Wen leaemon BNd • Suae LAUDS •SoWt Bend, Indiana4 o •. 574.135.5912• F: 570.2i5.021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III.OWNERSHIP <br />A. Type of ownership (check one): <br />Sole Proprietorship (If sole proprietorship, proceed to 1). <br />Partnership (If partnership, proceed to 2). <br />Corporation (If corporation, proceed to 3). <br />1. Sole Proprietor <br />Name: 010 .p ri 14 a In VI l Ct.��o <br />Residential Address: CIi{ F. rrkmAYI. .I <br />City: 11 L A4. d State: -IN Zip: 0(a 1 q <br />2. Partnership (List at least two (2) partners) <br />Name 81: <br />Residential Address: <br />City: I State: Zip: <br />Name N2: <br />Residential Address: <br />3. Corporation <br />Legal name of corporation: <br />Date and state of incorporation: <br />List officers and directors who own 15% or more of stock: <br />Name 1t1: <br />Business Address: <br />City: State: - Zip: <br />Residential Address: <br />Name <br />Business Address: <br />City: State: Zip: <br />Residential Address: <br />3 <br />