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For all municipal business license questions, mrnad: City of South Bend • Department of Community Investment <br />222 Wei[lenerson Blvd • Suits 1400 s •SmAn Bend, Indiana 46601 • 574.235,5912 • 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 />Business Address: <br />City: State: Zip: <br />Residential Address: <br />IV. PERSONAL DATA <br />A. Applicant's Legal We: 5a L LQ p <br />B. Residential Address: .I <br />City: 3ZA State: Zip: <br />C. Residential Telephone Number: <br />D. Residential Fax Number: /� CC <br />E. Celephone Number: 5741— 9 <br />F. E-Mail Address: f) Q' Ol r f c-e_k` <br />G. Position with business: <br />H. Please list all criminal Convictions (if any, excluding trafFlcviolations: <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 Stale Dates <br />