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For all munkipal bu lness Iloerue quesdmu, t4rdam CM of South Bend • Department of Community Investment <br />227Weotlefferson Blvd • Suite 14005 -South Bend, Indiana "601 • 574.235.5912 • F:574.235.9021 <br />LICENSE APPLICATION FOR -MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4.35 <br />Ill. OWNERSHIP <br />A. Type of ownershi 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: S <br />Residential Address: <br />Gty: State: - Zip: 'Ay6=0.N'� <br />2. Partnership (List at least two (2) partners) <br />Name #1: <br />Residential Address: <br />City: State: Zip: <br />Name N2: <br />Residential Address: <br />City: State: zip: <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 #1: <br />Title: <br />Business Address: ' <br />City: State: Zip: <br />Residential Address: <br />City: State: Zip: <br />Name #2: <br />Title: <br />Business Address: <br />City: State: Zip: <br />Residential Address: <br />City: State: Zip:_ <br />2 <br />