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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 – CARNIVALS AND CIRCUSES <br />MUNICIPAL CODE SECTION – 4-22 <br /> <br />III. PERSONAL DATA <br /> A. Applicant's Legal Name: <br /> B. Residential Address: <br /> City: State: Zip: <br />C. Residential Telephone Number: <br />D. Cellphone Number: <br />E. Social Security Number: F. Gender <br />G. Race: H. Date of Birth: <br />I. Position with Business: <br /> <br /> <br />IV. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION <br /> <br /> V. INCLUDE WITH APPLICATION, A SITE PLAN, DRAWING OR DIAGRAM OF THE CARNIVAL OR CIRCUS <br /> <br />VI. INCLUDE WITH APPLICATION, PROOF OF LIABILITY INSURANCE WITH THE CITY OF SOUTH BEND <br />LISTED AS AN ADDITIONAL CERTIFICATE HOLDER <br /> <br />VI. AFFIRMATION <br /> <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 and affirm that I have in no way attempted to <br />mislead the city in this application by omitting facts known to me. I agree to permit periodic inspection <br />of my equipment by the Board of park Commissioners or their agent. I have read and understand the <br />regulations of Carnivals and Circuses license found in the City of South Bend Municipal Code, Section <br />4-22. <br /> <br /> <br /> <br /> Signature Date <br />