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For all municipal business IIcents questions, contact; City of Sound Bend • oeFanmemt nl Communny In"Stmem <br />327West Jefferson BlvE•Suite 1400 S•5cxth Send, Indiana 46WI- 594.1355912 IF: 5]d.=P.9021 <br />o)tas�i 9105.°0 <br />LICENSE APPLICATION FOR- MASSAGEESTABLISHMENToASN <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 Na e: 1' a.r 7--- w <br />B. Residential Address: <br />City: State: - .Zip: <br />C.Residential Telephone Number. (o2.(P -7Z <br />D. Residential Fax Number: <br />E. Cellphone Number: <br />F.E-Mail Address: Li4'no a7 4509ILr 0 01mgf1I, Coven <br />G. Position with business: rs+.: n e I— <br />H. Please list all criminal convictions (if any), excluding traffcviolations: <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 />2o22Zo 2bS <br />(Attach additional sheets if necessary) <br />J <br />3 <br />