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For all municipal business license questions, contact: City of South Bend • Department of Community Investment <br />227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021 <br /> <br /> <br />2 <br /> <br />LICENSE APPLICATION FOR – ADULT BUSINESS <br />MUNICIPAL CODE SECTION – 4-18.5 <br /> <br />III. PERSONAL DATA (Owner) <br />A. Applicant’s Legal Name: <br />B. Residential Telephone Number: <br />C. Cell Phone Number: <br />D. Residential Address: <br />E. City: State: Zip: <br />F. Social Security Number: G. Gender: <br />H. Date of Birth: I. Race: <br /> <br /> OPERATOR (if different from owner) <br />A. Operator’s Legal Name: <br />B. Residential Telephone Number: <br />C. Residential Address: <br />D. City: State: Zip: <br /> E. Social Security Number: F. Gender: <br />G. Date of Birth: H. Race: <br /> <br /> Registered Agent (if applicable) <br />A. Agent’s Legal Name: <br />B. Residential Telephone Number: <br />C. Residential Address: <br />D. City: State: Zip: <br /> E. Residential Telephone Number <br /> <br />IV. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION <br />V. INCLUDE, WITH APPLICATION, A SKETCH OR DIAGRAM SHOWING THE CONFIGURATOIN OF THE <br />PREMISES. <br />VI. AFFIRMATION <br />I, hereby, certify and affirm that all of the information I have given in this application is true and <br />accurate to the best of my knowledge. I further certify that I have in no way attempted to <br />mislead the City in this application by omitting facts known to me. I have read and understand <br />the regulations of the Adult Business license found in the City of South Bend Municipal Code, <br />Section 4-18.5, 12-1, 12-2, 12-3, 12-3.5 AND 12-6. <br /> <br /> <br /> <br /> Signature Date