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For all municipal business license questions, contact: City of South Bend • Department of Community Investment <br />227 West Jefferson Blvd • Suite 1400 S -South Bend, Indiana 46601 • 574,235.5912 • F: 574,235.9021 <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 Name: L I <br />B. Residential Address: i, <br />City; �;o a L:j`` � i State: _Z V Zip: 4 60 <br />C. Residential Telephone Number: <br />D. Residential Fax <br />E. Cellphone Numl <br />F. E-Mail Address: <br />G. Position with business: 0 W,j��Y <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 />(Attach additional sheets if necessary) <br />J. <br />K. <br />L. <br />M <br />3 <br />