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For all municipal business license questions, contact: Clry of South Bend • Department N Community Investment <br />222 Wert Jefferson BIM • Suite 14W S South Bend, Indiana 46W1 • 524.2353912 • F: 574.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <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 />CC,ty. State: Zip: <br />IV. PERSONAL DATA <br />A. Applicant's Legal Name: Hzi& rrV--d��y'�L L�L y�t�/ <br />B. Residential Adddre�ssy IY,-t',I r73 ''1 �L-fJ(.4'�IL�A.'�'i�1 I)r- �1 <br />City: State: IN Zip: f G lof I <br />C. Residential Telephone Number: <br />D. Residential Fax Number: <br />E. Cellphone Number: f/r]1�-850-'S� <br />F. E-Mall Address: $i j&nPV 57q @�a'Vt�cl Com <br />G. Position with business:YJP.y1X.�-bT' <br />H. Please list all criminal convictions (if any), a eluding trafficviolations: <br />Nature of Conviction City State Date <br />(Attach additional sheets if necessary) <br />I. Please list all addresses forthree (3) years prior to application date: <br />Street Address City State Dates <br />313-E,, Q Wq AW I'M& St, wq oef ae28— act } <br />( <br />K. <br />L. <br />