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For BitmunicipalWou al business license queitbrq, mntatt' City ofsauM Bend. <br />aD Wenrerhrson BW • suite I4w S: •S',, Ba ntl, Indiana <br />vecartmem areomme,;; <br />WS01 •s)4.Tgs9 2. 57,.V Inv>> <br />s a 1 <br />LICENSE APPLICATION <br />FOR — Mq ESTAB.so <br />MUNICIPAL CODE SECTTIONIOIV ESTABLISHMENT <br />, q•35 <br />III. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name #3: <br />Business Address: <br />IV. PERSONAL DATA <br />A. Applicant's Legal <br />B. Reside...:.a <br />C. Residential Telephone Number state: <br />Zip; <br />D. Residential Fax Number: <br />E. Cellphone Number: <br />F. E-Mail Address: _ <br />G. Position with business: Omar <br />H. Please list all criminal convictions (if any), excluding trafficviolatlons: <br />Nature of Conviction <br />City State <br />Date <br />(Attach additional sheets If necessary) <br />I. Please list all addresses for three 3 - <br />( ) Vears prior to Street Address application date: <br />City State <br />Dates <br />-�^rt�cflf� yL/U �6- <br />