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For all munIdpal buslness Hoarse questions, mmacn City of South Bend • Deyartment of Community Investment <br />227 West Jefferson BIM • Surte 1400 S -South Bend, Indiana M601. 5]1235.5912. F: 524.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name p3: <br />Title: <br />Business Address: <br />City: .State: Zip: <br />Residential Address: <br />City: State: Zip: <br />IV. PERSONAL DATA n� <br />A. Applicant's Legal Name: Ra— <br />rril IRDfYlDm <br />S. Residential Address: <br />r <br />City: ` hk W state.?♦) Zip: ULIt15 <br />C. Residential Telephone Number: IN -50-.3&q <br />D. Residential Fax Number: <br />E. Cellphone Number: mq - 3qqq <br />F. E-Mail Address: <br />G. Position with business: OWD1Y D tta <br />H. Please list all criminal convictions (if any), excluding trafficviola ions: <br />Nature of Conviction City State Date <br />Y1DV1l <br />(Attach additional sheets IF necessary) <br />I. Please list all addresses for three (3) years priorto application date: <br />Dates <br />lolJtolB - cwrcn} <br />1 l <br />h ry) <br />3 <br />