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For all municipal business Ilene quesdons contact. CMof South Bend • 0epartment MCommuni, ImestmeM <br />227Westlefkrson BHd • 5uae 14W 5 •SoudA Bend, Idiada g5601.574.235.5912 • F: 574.aSS021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name ft3: <br />Business <br />Residential Address: <br />IV. PERSONAL DATA <br />A. Applicant's Legal Name: <br />L <br />B. Residential Address: —,517) Fp F 6U tM Lt cif (.( <br />City: S-,,�.n f c/ Slate: ,/ - 4 <br />Zip: <br />C. Residential Telephone Number. <br />D. Residential Fax Number: <br />E. Cellphone Number.--Sl �/ - 3 p i - 2 Z2 <br />F. E-Mail Address: �' ,/-/tg i a 1v h (,'Pfl . (y q Oil <br />G. Position with business: � 1 . 4 Y <br />H. Please list all criminal convictions (if any), excluding trafficviolations: <br />Nature of Conviction City.. State <br />Dale <br />(attach additional sheets if necessary) <br />1. Please list all addresses for three (3) years prior to application date: <br />Street Address City State <br />Dates <br />