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For all municipal business license questions, wnta": City of South Bend • 0epaitment MCommunily Investment <br />227WeRJefferson BIM • Suite 14005 -South Bend, Indiana ;S601 • 574.235.5952 • 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 M3: <br />Business Address: <br />City: State: <br />Residential Address: <br />City::. <br />A. Applicant's Legal Name: <br />B. Residential Address:. <br />City:_State: <br />C. Residential Telephone Number: <br />D. Residential Fax Number. <br />E. Cellphone Number: S 7 N <br />F. E-Mail Address: <br />n <br />b' ri ✓F 7- A e S &1&3S dpa. {' 4rHdf <br />f <br />G. Position with business: AD LUYIQrV <br />H. Please list all criminal convictions (if any), excluding trafficviolations: <br />Nature of Conviction City State <br />Date <br />(Attach additional sheets if necessary) <br />I. Please list all addresses forthree (3) years priorto application date: <br />City State <br />Dates <br />S8 �� <br />�11etc iZI <br />