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For all municipal business Ilcanse questions, concede City of South Bend' Department of community Imicamment <br />227 WertlNkrson Blvd ISO lee 10005'South Bend, Indiana 06601 • 579.B5.5912 • F. 576.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III.OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name k3: <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 N <br />B. Residential Address <br />City: i 4 State: Zip: <br />C. Residential Telephone Number: III.ajJbi.- <br />D. Residential Fax Numb : N orb., A <br />E. Cellphone Number: <br />F.E-Mail Address: C9c GlfnW,, GOM <br />G. Position with business: WnQ.r <br />H. Please list all criminal convictions (if any), excluding traffic violations: <br />Nature of Conviction City State Date <br />/.II/A- <br />(Attach additional sheets if necessary) <br />I. Please list all addresses forthree (3) years priorto application date: <br />Street Address `` City State Dates <br />�r1GMf A� IwJbaFt_ <br />