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For all municipal business license questions, contact; City of South Bend • Department of Cammunky Invennent <br />222 Wert Jefferson BI W • Suite 1400S •South Bend, Indiana 16601 • 574235.5912 • F:52A21SM21 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name H3: <br />We: <br />Business Address: <br />City: State: Zip: <br />Residential Address: <br />City: State: Zip: <br />IV. PERSONAL DATA <br />A. Applicant's Legal Name: MPa LIB SW 110814011 AP <br />B. Residential Address: 1fp l.C' Jay k0a, <br />city; AA, ( ) ai,/" State: l u Zip: kE-wr <br />C. Residential Telephone Number: <br />D. Residential Fax Number. <br />E. Cellphone Number. 1 � p� <br />F.E-Mail Address: 12.40 GS VZO Oa Lim` CIDM <br />G. Position with business: DI.Ih1 P1" <br />H. Please list all criminal Convictions (id any), excluding traff cviolations: <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 />14 L 3 I IxtV �z�r..i M k ai1' 4 flh -,w $-present <br />